Report of the
President's
Biomedical Research
Panel
SUPPLEMENT 3
Written Statements
Supplementing Verbal Testimonies of Witnesses
Id/^ ^^9U'2 v^^ ^^- ^ ^'^ ^ v^^p-?
_Report of the
President's
Biomedical Research
Panel
SUPPLEMENT 3
Written Statements
Supplementing Verbal Testimonies of Witnesses
April 30, 1976
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
(,/.5, Public Health Service
DHEW Publication No. (OS) 76-508
For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402 - Price $3.70
Slock No. 040-000-00353-3
The President's Biomedical Research Panel was established on January 29, 1975, and charged,
under Public Law 93-352, to review and assess the conduct, support, poUcies, and management of
biomedical and behavioral research as conducted and supported through programs of the National
Institutes of Health (NIH) and the Alcohol, Drug Abuse, and Mental Health Administration
(ADAMHA). The legislation directs the Panel to submit a report of its findings by April 30, 1976,
to the President and to the Congress.
Over the period of fifteen months, the seven members of the Panel conducted an extensive
study that involved assessments of the state of the science, the impact of federally funded re-
search on institutions of higher education, the organization and management of the NIH and the
ADAMHA, the dissemination and application of research findings, and the development of policy
for federal support of biomedical and behavioral research.
The main volume of this report (DHEW Publication No. (OS)76-500) contains the issues iden-
tified by the Panel in its study and the Panel's subsequent recommendations. The annex included
in this volume details the methods of study used by the Panel and provides listings of witnesses
who appeared before the Panel in hearings, professional and volunteer organizations contacted
for submission of views, and resource materials available to the Panel in the course of its delibera-
tions. Four appendices and four supplementary volumes accompany the main report.
Appendix A, "The Place of Biomedical Science in Medicine and the State of the Science"
(DHEW Publication No. (OS)76-501), contains the reports of the Overview and Interdisciplinary
Clusters. In an unprecedented study, the Panel brought together preeminent biomedical and
behavioral scientists and asked them, on an interdisciplinary basis, to assess the state of the
science, to identify areas of promise and the resources required to achieve important new knowl-
edge, and to relate research to the health of the nation's people. The results of this effort are
contained within the reports of the eleven Interdisciplinary Clusters. The report of the Overview
Cluster focuses on the place of biomedical science in medicine.
Appendix B, "Approaches to Policy Development for Biomedical Research: Strategy for
Budgeting and Movement from Invention to Clinical Application" (DHEW Publication No.
(OS)76-502), presents the results of three studies performed under contract to the Panel:
(1) "Lags Between Initial Discovery and Clinical Application to Cardiovascular Pulmonary Medi-
cine and Surgery" (Julius H. Comroe, Jr.), (2) "Analysis of Selected Biomedical Research
Programs" (BatteOe-Columbus Laboratories), and (3) "PoUcy Analysis for Federal Biomedical
Research" (The Rand Corporation).
Appendix C, "Impact of Federal Health-Related Research Expenditures Upon Institutions of
Higher Education" (DHEW Publication No. (OS)76-503), presents a summary of findings and
conclusions of studies on the influence of federal funding of biomedical and behavioral research
upon the financial status and educational functions of research universities and academic medical
centers. The studies were conducted, under contract, by the American Council on Education, the
Association of American Medical Colleges, and The Rand Corporation.
Appendix D, "Selected Staff Papers" (DHEW Publication No. (08)76-504), offers eight papers
prepared by individual members of the Panel staff on a variety of topics pertinent to the NIH
and the ADAMHA.
All five of the above mentioned volumes are available from the Government Printing Office,
as indicated.
In addition, four volumes of supplementary resource documents are also available from the
Government Printing Office.
Supplement 1. "Analysis of Selected Biomedical Research Programs: Case Histories" (DHEW
Publication No. (OS)76-506). Background information for the study by
Battelle-Columbus Laboratories.
Supplement 2. "Impact of Federal Health-Related Research Expenditures Upon Institutions
of Higher Education" (DHEW PubUcation No. (OS)76-507). Findings, con-
clusions, and background information of studies by the American Council on
Education, the Association of American Medical Colleges, and The Rand
Corporation.
Supplement 3. "Written Statements Supplementing Verbal Testimonies of Witnesses" (DHEW
Publication No. (OS)76-508).
Supplement 4. "Statements of Professional, Scientific, and Voluntary Health Organizations"
(DHEW Publication No. (OS)76-509).
Verbatim transcripts for all meetings of the Panel, except the March 1975 meeting, are avail-
able from the U.S. Department of Commerce, National Technical Information Service,
Springfield, Virginia 22161.
CONTENTS
Page
American Heart Association 1
American Institute of Biological Sciences 9
American Nurses' Association 21
American Psychiatric Association ' 39
American Psychological Association, Division 77
of Population Psychology
American Society of Hematology 105
American Society for Microbiology 129
Council of the American Association of Chairmen " 133
of Departments of Psychiatry
Federation of American Societies for Experimental 1^9
Biology
The Joseph and Rose Kennedy Institute for the 157
Study of Human Reproduction and Bioethics
National Advisory Mental Health Council 167
National Association of Life Science Industries 179
National Association of State Drug Abuse Program 1 85
Coordinators
National Council of Chairmen of Graduate Departments 199
of Psychology
National Council on Alcoholism 205
National Urban Coalition Task Force on Health 211
Population Association of America, Committee on 2^9
Population Statistics
Reproductive Biology Research Foundation 265
Social Security Administration 273
AMERICAN HEART ASSOCIATION
PRESENTATION FOR PRESIDENT'S BIOMEDICAL RESEARCH PANEL
SUMMARY
While distinctions between basic and fundamental research, on the
one hand, and clinical and applied research, on the other, have some
conceptual value, priorities in the allocation of research funds should
not be established solely in reference to them. Priorities should be
determined by the degree of excellence of each application, with the
criteria for judging such excellence; varying according to the type of
activity proposed. Priorities should also reflect the value of stimulating
investigator- initiated research and the need to revitalize continually
the research community through on-going programs for developing research
talent. The existing structure of the National Institutes of Health has
served these purposes well and there would appear to be no reason to
dismantle it. Attempts to alter the NIH review process \'ould be particularly
Inadvisable.
The Institutes should have and exploit responsibility for disseminating
information on the clinical ramifications of new knowledge and/or encourage
the scientific community to do so. They do not, however, have the capabil-
ities for direct interface with the public. This should be accomplished
through a partnership with other agencies having broader connections with
the communities to be served. ■
DISCUSSION
All well thought out types of research approaches are worthy of
meaningful support. Although relatively new, goal-oriented investigation
has already contributed much to the treatment of disease. The Myocardial
Infarction Research Program, for instance, has been responsible for several
new techniques which have proved to be of major clinical value. Among
these are the Swan-Ganz catheter which has significantly changed the approach
to the therapy for patients with acute myocardial infarction and pump
failure, since it facilitates safe and routine hemodynamic study at the
bedside. A number of drugs have been evaluated in the setting of acute
myocardial infarction, showing that much of our previous therapy was
ineffective and that newer agents which we had previously thought to be
dangerous were indeed safe when indicated. Another contribution was the
introduction of radioactive tracer techniques for non- invasive evaluation
of ventricular function of patients with acute myocardial infarction and
the newer radioactive imaging techniques to determine areas of heart
muscle damage. Similarly, the group at the Massachusetts General Hospital
under the auspices of the MIRU program has shown the clinical utility of
intra-aortic balloon pumping for relief of ventricular fdlure associated
with acute myocardial infarction. Because of their experience, the intra-
aortic balloon pump is now being used throughout the world in post-
operative patients who have difficulties recovering from left ventricular
bypass. The use of this pump has, in the opinion of many surgeons, markedly
reduced mortality following heart surgery. These are but a few selected
examples of advances which arose from the MIRU Program.
No matter how impressive the results of applied or clinical research,
however, continued advances in the delivery of health care demand the
simultaneous study of basic and fundamental mechanisms. Furthermore, basic
investigation can support claims of ultimate significance for the treatment
of human disease equal to or surpassing those noted for clinical and
applied research. For example, within the field of thrombosis, fundamental
2
research has yielded many unanticipated therapeutic gains. Thus, the
anticoagulant, heparin, was discovered by a medical student searching for
a procoagulant activity in liver. The anticoagulant, Dicumarol, was
recognized during the search for the basis of hemorrhagic spoiled sweet
clover disease in cattle. From the incidental observation that the anti-
hemophilic globulin was the last plasma protein to go into solution as
frozen plasma thawed, came the development of factor VIII concentrates
that revolutionized the treatment of hemophilia. In vitro studies of
platelet aggregation, in many laboratories throughout the world, have
resulted in the recognition of pharmacological agents that inhibit this
process and a variety of these compounds are currently undergoing clinical
trials as antithrombotic agents in such major areas as heart attacks and
stroke. From a chance observation Ln a patient that a trace quantity of
heparin profoundly augmented the activity of antithrombin III, came a
biochemical rationale that has stimulated the current extensive trials of
prophylactic low-dose heparin that may have an impact on the primary
prevention of postoperative pulmonary embolism, a serious killer of adults
annually in this country.
Other important pay-offs in he.art and vascular disease which came
about from basic research include tne following:
(1) The elucidation, by a number of workers, of the mechanism
of blood pressure regulation has made it possible to treat hypertension
effectively.
(2) The discovery that sulfonamides increase urinary salt and
water excretion led to their use as clinical diuretics. Diuretics are
recognized as one of the most useful group of drugs for the treatment of
cardiovascular-renal disease. Furthermore, the unique properties of
diuretics stimulated basic questions and new insights into how the kidney
manufactures urine.
Additionally, from the point of view of kidney disease, one of the
most celebrated contributors to clinical insights in nephrology was
Homer Smith, who was a basic scientist and not a physician. Many of the
fundamental physiologic techniques used today were advanced by Dr. Smith.
Finally, at a universal level, let us not forget that the discovery
of x-rays by Roentgen in 1895 is an excellent example of basic research
applied on a massive scale to clinical medicine.
As stated above, all kinds of research are worthy of meaningful support.
The real issues are qualitative and quantitative. Appropriate criteria can
be developed to judge the excellenc<i of both basic and applied research.
In basic science and applied clinical science, the best idea should
capture the funds, whereas relevance is an important determinant in regard
to where funds should be expended for demonstration of effectiveness of new
modalities. To assure excellence, moreover, the bottom line of funding
cutoff for each category should be the same.
The question of excellence is inextricably tied with the NIH peer
review process. The concept of peer review has been basic to the past
success of the NIH research programs. Changes in the technique of peer
review, such as public review proceedings or dissemination of grant appli-
cations or their critiques, would detract from critical, honest appraisal
of grant applications and/or the investigators concerned and would not
advance the quality of research supported. Techniques for the administration
of the review process at the national level such as continual, critical
appraisal of the success or failure of individual funded projects, frequent
turnover of reviewers and multiple reviews when necessary in controversial
proposals may in the end be more useful mechanisms to provide fair review
process than merely hobbling critical and honest appraisal of reviewers.
As for quantity, provision must be made to assure sustained funds for
research on the frontiers of knowledge. The imposition of short-term goals
and sudden deviations of large segments of the biomedical community to
activities hastily conceived as "relevant" is not the most effective route
to progress in biomedical science.
Aside from a core support for l^asic research, two indices could be
applied to determine appropriate levels of research funding. One would
be the morbidity and mortality whicli could be alleviated by the research.
The cost/benefit importance of savings in health care and welfare costs
cannot be overemphasized. Nevertheless, in taking into account the social
and economic impact of research, we must also keep in mind the potential
new and additional costs which may be engendered by the solution of a disease
process — a large and debilitated elderly population, for instance.
Another useful index could be the complexity of the disease process
under study. Emphasis on this point will enable the layman and his
political representatives to understand the tremendous creative effort
and time needed to solve certain health problems. The public's impatience
with and distrust of the scientific community, which has newly surfaced,
could thereby be deflected.
Contract research is clearly desirable at times because it enables the
supporting institution to reach specific predetermined scientific goals.
On the other hand, contracts usually carry a much higher price tag than the
traditional grant and they eat up a large portion of the Institutes' budgets.
Some in the scientific community are concerned that the growth in contract
research, in a period of lessened federal support of research, has limited
the funds available for investigator-initiated inquiry, especially since
discovery and new knowledge generally is associated with freedom of the
investigator to follow his own line;; of thought without administrative
restrictions. Perhaps what is needed is a new form of research support
which combines the best features of the contract and the traditional
grant. This new funding mechanism would include solicitation of projects
with predetermined endpoints but allow the competitors to decide what form
the research should take and how it should proceed.
The ultimate question of quantity, of course, is the gross amount of
funds available for research activity. In this regard, a categorically-
based research effort probably assures a flow of research dollars as large
as politically possible. The "organ" or "disease" oriented approach is
probably the best way to appeal to the general population for substantial
continued support. A "fight against disease" that can be reinforced through
contacts in the daily round is easier for the average citizen to understand
and support through taxes than random thrusts into the expansive unknown
of biology.
The Scientific Councils of the American Heart Association believe that
the present framework for governmental support of biomedical research can
effectively and efficiently meet the needs and opportunities for scientific
inquiry. Each Institute supports a wider range of investigation than their
name alone would imply, and all support a substantial amount of basic research.
We understand that there is some concern that the biomedical community has
not responded adequately to the newer health problems of society — lack of
motivation, drug and alcohol abuse, etc. We believe that the biomedical
community is aware of and concerned by these problems and that it is willing
to add its expertise to their solution if given the proper direction.
Perhaps a special branch of the NIH should be established to stimulate
research activity in these areas and to point the way for the first steps.
The mission of the NIH from its inception through the early 60 's was
to generate new knowledge of high quality. This mission should be brought
back into focus. And although much needs to be done to improve the process
of translating scientific progress to health care practice, efforts by the
Institutes along these lines should not detract from their primary function.
The Institutes, for instance, do not: have the capabilities for a large scale
direct interface with the public. Such an interface would be very expensive
to create and would duplicate networks already operated by voluntary health
agencies with categorical interests. The confusing and frustrating potential
of such duplication became apparent in those few instances where the main
contractor of the National Heart ancl Lung Institute High Blood Pressure
Education Program tried to set up community screening programs at the local
level which were unwittingly in competition with Heart Association chapters
and affiliates. Federal efforts should instead be directed to development
of new modalities for affecting behavior, not only as a preventive measure,
but also among patients and providers. Then local agencies can use these
modalities in their approaches to these populations.
AMERICAN INSTITUTE OF BIOLOGICAL SCIENCES
I am Dr. Richard Trumbull, Executive Director of the American
Institute of Biological Sciences, a federation of over 50 biological
scientific societies, and the publisher of the journal BioScience .
While this position has brought me into closer contact with the
biomedical world, my previous years in research and its management
at the Office of Naval Research, especially as the Director of
Research, exposed me to a broader spectrum of disciplines, programs
and problems upon which I will draw for what I wish to emphasize.
This position, at AIBS, has brought me into closer contact with
the bio aspect of your world of biomedicine. The world of health
and medicine is rapidly increasing its perspective to include not
only the whole man but his total environment, as well. We are just
beginning to appreciate the multitude of things which influence
the physical and well being of man and become manifest in the ills
to which medicine attends. Foremost in the disciplines developing
our understanding of these variables is that of biology. The first
courses which separated those who were to enter medicine from those
headed into other professions were in the biological sciences.
This was the base, the introduction to scientific method, the
understanding of systems and functions. The validity and reliability
of this knowledge was vital because it formed that base. Even as a
practicing physician, one constantly draws upon the progress in the
same biological fields when he prescribes diets, recommends
pharmaceuticals, accepts interpretations of slide materials, and
resorts to radiation therapies. The assurance one must feel in the
practice of medicine because these basic skills supporting him are
constantly being honed leads me to believe that just restating this
relationship between biology and medicine will remind you of one
major priority for a biomedical panel - that of maintaining the
base for the next generation.
Having set that stage, let me continue on another aspect of
research and development. My concern is with the policies, practices
and procedures which have hindered those charged with making
decisions affecting the advancement of our sciences and technologies.
There will be no plea for more funds for basic research without
better mechanisms for their expenditure and accountability. Nor
would I presume to recommend priorities in support of disciplines
or programs within disciplines promising a broader, firmer base for
future advance or a more immediate return for technological
application.
As a format, let me take you through the research and develop-
ment process from the support of basic research to applications and
public appreciation of science and technology with comment along
the way on some of the concerns and potentials which appear to be
appropriate for a panel in the Executive Branch of government.
Research Support : Tempting as it is to suggest continued
increases in funds for basic research or the establishment of some
percentage of GNP or some other formula for obtaining what others
choose to call a "fair share" for biomedical research, I believe that
assured support on schedule is more important. It is a paradox that
those who express concern about peer review and other mechanisms of
proposal evaluation which, at best, influence a few investigators,
10
contribute to funding vagaries far more destructive of the total
research potential each year. Delays in Congressional and Executive
release of funds,, now an accepted and widespread practice, disrupt
the required orderly process of program review, proposal review and
allocation of support. Because of this accepted way of doing
business the more promising research is reduced to a maintenance
level for protection, academic positions are placed in jeopardy, and
graduate training of another generation is interrupted or terminated.
Those submitting proposals in response to a legitimate Request For
Proposals (RFP) have invested funds in their preparation with some
expectancy of support. Smaller institutions cannot afford repetition
of these costs and conscientious program managers should not have
first contacts clouded by unnecessary feelings of distrust. The
above is worded carefully because there are program m.anagers who
place the system in jeopardy by post facto RFPs and those issued to
establish a pressure on those above them in the system. This, too,
has to change.
There seems to be some conception that this whole process of
research operates like a water faucet. It is ready to flow whenever
the tap is turned on. However, for too many years, this delayed
turning of the tap has caused an abrupt overload for a system
already over burdened with paper work and necessitates a rearrang-
ing of priorities related to the applicants still available, and
inevitably, a spontaneous "dumping" of badly needed funds just to
get them expended. I mention this executive problem as a preliminary
on funding because we do not know the quantity and quality of basic
research we could support were the Congress more sensitive to the
need for an assurance of support on schedule. This wasteful "feast
or famine" funding vitiates evaluation of the whole process of
planning, supporting and implementing. Yet, the public and Congress
asks for a full accounting of the funds thus made available as if
this process had been optimum.
This "full accounting" raises another critical issue, that
of legislated utilization of research funds for the satisfaction of
socio-economic-political goals. Worthy as they may be, the
constraints imposed on optimum realization of basic research potential
by specifically requiring that some portion of the funds available
be expended in support of small business or to induce a migration
of scientists to some particular type of educational institution or
to some particular state or region, or to rectify the social ills
of decades must be recognized for what they are - contraints . It
is folly to expect a 10.0% science return when 30% - 40% of the funds
are preempted for other goals. Considering these prevailing funding
practices, I believe that we have been getting a fairly good return
on that part of the dollar research really receives.
What I have said so far pertains mainly to the governmental
agencies and their support of science. I am assuming that this Panel
seeks the best supportive structure available, so we must recognize
that there are some far reaching problems in the industrial sector,
also. If patents, copyrights and other incentives are dealt with
properly, industry will resume its support of an appropriate share
12
of basic research. The same applies to state agencies. Such a
spreading of the support of our research base should be one objective
of this Panel. Indeed, there are innumerable benefits to be derived
from fostering a closer relationship between the academic and
industrial research worlds, a relationship which" has been thwarted
by increasing reliance and dependancy of academe upon the Federal
government. Before we leave this concept of the research base, I
must reflect my present area of interest and concern. Recognition
of the biological sciences as the base for progress in solving our
medical, health, agricultural and population problems has been very
slow in evolving. In the past, they have not enjoyed the drama
associated with atomic bombs, space flight and computer developments.
Now, we are constantly being reminded that the time for establishing
our basic research structure for dealing with these more significant
problems both at home and abroad is passing by. I mention this
because, quite appropriately, the sequence in the real world has
been represented in the title of this panel - bio medical . Retro-
fitting or waiting for basic research to catch up is costly in
both time and money so it is necessary to start at the beginning
with the biological sciences.
Management : Recently research management has come under fire.
One has the feeling that he has been there before. Over the years
since research became of major National interest, there have evolved
a number of management styles. The major variable has been the
point in the system at which programming occurs. Someone has to
view the interrelationship between the tasks which are supported
and the relationship between the program and some objective. This
concept meets with much resistance and has been buried beneath
a great deal of emotionalism. It is imperative, however, to
satisfy management's requirement for justifying what one is doing
and why in light of competition with other demands upon limited
funds where competitors are willing and capable of making such
justifications. It is absolutely necessary to justify expenditure
of the taxpayer's funds, especially when he cannot understand most
of the scientific terminology related to individual research tasks.
Programming can serve many fruitful functions. Properly
perceived and structured, it can provide maximum honing for the
cutting edge of a science. It can achieve interaction of disciplines
to assure development of their interfaces. Further, it can improve
apportionment of funding across research entities and thereby enhance
better understanding of a function, organic system, physical system,
or disease. Obviously, the agency head has to perceive such a
composite by definition of his title. A program director, a
division director, and others within an agency or industrial research
structure have similar requirements. Certainly, the concept of
"steering" committee implies that such is their orientation. We
experience problems in asking for such a perception of the goal
by "advisory" committees compounded by variations in individual
desires of advisory committee members to see the bigger picture.
Finally, we have the same variations in the interest of the basic
researchers themselves in the objective (s) of the program manager -
as to just how their research fits into some scheme. I believe
that those researchers who demand funds to do their own thing
Ik
according to some magic intuition, professing no interest in what
will happen to their work are a very small albeit a very vocal
minority .
Whether an investigator's knowledge of a program's objective
inhibits the truly basic aspect of his research, however, is his
own decision. Certainly, it is_ possible to structure and manage
research programs incorporating the work of many basic research
tasks without imposing any such consideration upon the investigators
involved.
A more difficult level for a decision on required knowledge
of program objectives is that represented by the "peer review"
as found in the advisory committee. There must be criteria against
which proposals are evaluated. One assumes that the "peers" have
some intuitive criteria evolving from personal research or a wide
reading familiarity in the same area. These criteria would include
research design, statistical treatment of data, equipment required,
credentials of investigator, et cetera. Numbers or letters can
indicate preferences in the absence of any explicit statement of
"preferences for what" or understanding of the et ceteras. This
can be done and has been done. While the role performed is intended
to be advisory to a program manager, it takes on other forms where
the agency representative is not perceived as a manager and/or peer
by the advisory committee. Here is one of the major management
problem areas to which more attention should be given. It arises
from the qualifications and accepted role of the agency manager and
the explicit charge to the advisory committee.
15
Unfortunately, many agencies have experienced unnecessary
difficulties in evolving and instituting effective management
procedures due to lack of definition in these areas. As emphasis
upon programming and targeting replaced the mere supporting of
research, the necessary re-evaluation of agency personnel and restate-
ment of function for such committees did not take place. It is
futile to expect a directive to achieve acceptance of peer or
leadership roles for the new manager or dampen a committee's ardor
to exercise management prerogatives in the absence of concomitant
responsibilities.
I would comment just a bit further on the program manager
situation. This key role in the progression from basic research to
application has been treated with some indifference. Many of these
positions have been filled by individuals whose length of service
required promotion. Many have been and are filled as a "year-in-
Washington" means for occupying a sabbatical. Both of these
management policies imply an insignificance or irrelevance that is
inappropriate. The requirements in this position for a broad -under-
standing of a scientific discipline, a sensitivity to the cutting
edge, an awareness of potential applications, a capability to worK'
with and coordinate the efforts of a group of scientists and,
finally the ability to report on the product and defend its priority
among other disciplines to management and Congress dictate a far
more serious program for selection and training of program managers.
This is one of the most interesting, challenging and vital roles
in our research-development structure. When provided appropriate
recognition and acceptance in that structure, you should have little
of the difficulty now experienced in recruitment.
16
Re-view is another area in managemont where an explicit charge
is necessary. It has been assumed that review committees re-view
the performance on grants/contracts approved in prior years - that
such an appraisal of progress is another determinant for consideration
of new proposals. This is one of the weakest links in the management
system - the accounting for previous expenditures for the sake of
management and the assurance of progress for the benefit of science.
Surely, I would not propose a moratorium on new funding of research
until we had a better picture of where we are or utilize what we
have learned, but I do favor improvement in the critical assessment
and communication of what has been done.
In those agencies which support research both in house and
elsewhere, there is a need for some representation of the total
program supported and interaction between participants in both
programs to improve mutual recognition and appreciation of roles
and talents. Despite the magnanimity and service orientation
attributed to scientists, there is a need for a greater feeling of
"teamwork," coordinated search for solutions, cooperative develop-
ment of education and training programs, and recognition and
appreciation of contributions of others. This need extends within
and across disciplines. In short, there is an individualization,
a competitiveness that is counterproductive and inhibits achievement
of societal goals. It is believed that the full potential of science
will not be realized in this environment and that governmental
programs constitute unique vehicles for their development by elimina-
tion of management mechanisms which encourage their continuance.
17
We have spent vast sums on computer systems for recording
the presence and content of research tasks supported by a variety
of governmental agencies. However, there is little evidence that
any agency is routinely obtaining such information as a background
for program planning. Some years ago, there was an Integrated
Life Sciences Exchange brochure which listed every contract/grant
under way in the life sciences. It was invaluable to program
managers for filling holes, preventing redundancy and avoiding
duplicate funding for research tasks. Here was a management tool
which provided both an incentive and a means for procuring the
maximum return for one's limited research dollars. Apparently, the
intervening years have not seen the increased utilization of such
information as warranted by the relatively high return for the time
and effort invested. Unfortunately, we did not develop our
capabilities in this area while more funds were available. Now
we are faced with reduced funds, greater pressure than ever to
establish priorities and target research, and increased questioning
of our intent and competence. In short, we find it necessary to
hone our weapons in the heat of the battle.
Communications : Communication of research results forms the
basis for development and the visible return on our investment in
basic research. We do not adequately understand the progression
from research results to utilization although we have reports which
tend to establish the presence of, if not the need for some lead
time, the length of which can vary as evidenced by some pleas for
understanding of basic research. I once asked a program manager
in a military setting why things were implemented so much
differently during the war and the reply was "because we had a war
on." This motivational aspect requires more serious consideration
than it has received- Th(^re is serious danger to this acceptance
of some concept about a nine-year to fifteen-year lead time.
I believe that this Biomedical Panel should play a role in under-
standing and accelerating this process.
Such acceleration and the attendant review of mechanisms are
required as agencies are assigned roles in such functions as the
setting of standards, and determining tolerable and penri.issible levels,
It should be of concern to this Panel that it was the legislative
branch of government that removed DES from the market place
(Senate bill S963) . Such action accompanied by charges of
"ineffective regulatory action," reflects both a lack of confidence
in the appropriate agencies charged with such responsibilities and
a sensitivity to public response that bodes ill for the future of
science. The same is true of other intervention in program planning
and management in the agencies with responsibilities in the support
of research. Such activities might be explained by the proximity of
elections but they never should be excused when one recognizes the
cost in unwarranted loss of public confidence in so basic an element
in our social progress as science. It is inevitable that we shall
experience more of this as agencies set standards and requirements
pertaining to technological advance that are beyond possible
realization. This process might convince the public that the
lawmakers and the agencies are working in their behalf but it does
so in an atmosphere that implies such constant guard must be
19
maintained against some new ogre - technalogy . The ideals of zero
emission, zero contamination, and total safety must be balanced by
the costs associated with their attainment. Here cost can mean the
time spent in "being certain," in discouragement of new product
development through measurement and protection criteria beyond our
technological capability or at prohibitive cost, in developing
guidelines and controls when monitoring agencies also lack
technological capability and appropriate research methodology,
and in continued confusion of a public already uncertain as to the
role that science and technology are playing in their lives. The
National Science Board report {NSB-73-1, Science Indicators 1972 :)
states: "On the whole, public attitudes toward science and technology
appear to be positive. This is especially evident in their general
regard for science and technology, and their confidence in its
capacity to ameliorate national problems. Less positive opinions
were expressed, however, regarding the impacts of science and
technology, and the present uses to which it is put. On the whole,
the public attitudes appear to reflect more confidence in the
potential of science and technology than satisfaction with its
present applications."
All of us must assume some responsibility for that which is
past. Similarly, we must assume more responsibility for that which
is to come in the biomedical research and development world, whether
in the academic, governmental or industrial setting, to assure that
the public's confidence will be justified.
20
AMERICAN NURSES' ASSOCIATION
Mr. Chairman and members of the Panel, we are here on behalf of the
American Nurses' Association. The ANA is a national organization repre-
senting over 830,000 professional nurses giving health care in the United
States.
The significant increases in the cost of health care and the rising
expectations of the public for health care services have placed immense
pressure on these nurses to provide improved patient care and to reduce or
prevent health related problems. These actions can be effective only if
adequate nursing research is carried out to provide increased knowledge and
sound data on which nursing practice must be based. Nursing research is
aimed at the improvement of patient care and the reduction of heialth
related problems. Included are studies aimed at reducing the complications
and costs of hospitalization, studies which seek to develop knowledge and
methods for permitting home-based care in chronic illness, studies to
improve the outlook of high-risk groups such as premature infants, and
studies aimed at reducing the disabilities, discomforts, and costs of
coronary and cerebral vascular problems. Nurses are engaged in many other
areas of research which are leading to better methods of care, for example
in the areas of pain alleviation, care of burn patients, feeding of
comatose or disabled patients, home care during dialysis or parenteral
nutrition, management of dying patients, prevention of child abuse, and care
of the elderly.
To date, funding has been inadequate to permit the many studies urgently
needed in the areas described. Furthermore, in the future the need for
well prepared nurses who carry out patient-care-related research will be
even greater.
21
CLINICAL RESEARCH
Professionals outside the nursing arena are frequently unaware of the
immensely important changes which are taking place within this profession.
Recent innovations in nursing practice, such as the development of the
Pediatric Nurse Practitioner and the introduction of primary care nursing
have received a great deal of public attention.
The contributions of nursing research to the improvement of patient
care have, however, extended far beyond study of the delivery of health
services. The nature of nursing and of health care is such that many of
the health problems needing study cut across two or more disciplines and involve
concurrent application of knowledge and methods from both biomedical and
behavioral sciences. It is in this unique but specific area that nurse
researchers are making innovative contributions to the knowledge of health
care. These contributions are particularly applicable to the needs not only
for health care delivery but also for knowledge of disease prevention and
health maintenance. It is our purpose today to provide you with insight
into these areas of research which are currently being studied by nurse
researchers, to point to their current and future impact on health, and
to suggest areas of promise and urgency in future funding of nursing research,
CLINICAL AREAS OF INVESTIGATION
Nursing research is ultimately aimed at improving the care of people
with existing health impairments, and with identifying vulnerable groups
for whom preventive methods may be developed. The following are some of the
areas which are deemed to have high priority for nurse researchers. The
list is not intended to be comprehensive but is instead designed to indicate
selected important questions in nursing today.
22
studies to reduce complications of hospitalization and surgery (sleep
deprivation, anorexia, diarrhea, neurosensory disturbances, respiratory
infections, circulatory problems, and others )
This is one of the most active areas of nursing research today. These
research efforts are aimed ultimately at the solution of clinical problems,
but as in the following two examples, such research often involves
investigation of basic or underlying mechanisms as well as the application
this basic knowledge to the clinical setting and the therapeutic management
of patients.
A nurse physiologist at the University of Washington is using the most
sophisticated biophysical and physiological methods to define the effects
of changes in pH on cardiac contractility. This involves measurement of
tension generation in small bundles of cardiac cells using a method of
mechanically disrupting all membranes which allows precise control of
intracellular environment. , Conditions are created which occur clinically
including ischemia and hypoxia. Thus, she can define among other things
the optimum pH for reversibility of the effects of these conditions. She
is also investigating the interaction of a number of cardiac drugs with these
factors. This study grew out of a combined interest in muscle physiology
and in the care of post myocardial infarction patients who frequently undergo
wide shifts in pH as a result of the unique combination of pathophysiology and
therapeutic methods.
Another example of an area receiving study by nurse researchers is the
control of appetite under varying laboratory and clinical conditions. Monkeys
are studied in order to develop knowledge of the metabolic conditions under-
lying hunger and satiety. Comparisons of normal and obese monkeys are aimed
at elucidating differences which might be used in developing therapeutic methods
of appetite and body weight regulation. Parallel clinical studies of patients
23
receiving total parenteral nutrition or intragastric tube feeding are aimed
at understanding both the metabolic changes induced, and the effects of these
on behavior and appetite.
Studies to improve the outlook for high risk parents and high risk infants
A number of nurse researchers have studied premature infants and the
effects of altering the environmental stimulation on their growth and develop-
ment. Certain aspects of intrauterine environment, of which a premature infant
is generally deprived, have found to significantly improve indices of
developmental progress and weight gain. These include the systematic application
of a regimen of tactile stimulation, and the use of a rocking incubator with
auditory stimulation. Further research in this area will undoubtedly have
wide ranging effects on the care of premature infants and will lead to a
reduction in the incidence and severity of developmental problems in this
high risk group.
Studies to improve the health and care of. the elderly
At the Iowa Veterans' Home, a nurse has developed a variation of primary
nursing in order to increase both responsibility for and accountability for
nursing care among the aged residents. In Denver, another nurse is evaluating
the effectiveness of adult health nurse practitioners working in a primary
care capacity with physicians to deliver care to elderly patients of three
types: ambulatory, home bound, and residents of nursing homes.
Studies of life threatening situations, anxiety, pain and stress
Development of a scientific base of information on pain is the major
focus of another nurse researcher's investigation at the University of Iowa.
Several theoretical approaches to pain alleviation have been identified and
are now being tested by this researcher and her staff in the clinical
situation.
2k
studies of adaptation to chronic illness and the development of self-care
systems and group care systems
A nurse researcher at the University of Virginia has been studying for some
time the etiological factors in decubitus formation. Characteristics under
investigation are the temperatures at those sites where ulcers are prone to
occur, as well as the amount of moisture present, the downward pressure imposed
by the body, and the shearing force caused by the skin rubbing against the bed
sheet. Special instruments have been and are being designed to enable some
of these factors to be measured including use of an experimental bed surface.
One of the important outcomes of the study will be the identification of high-
risk factors in decubitus formation.
At Texas Women's University a nurse researcher has recently completed a
difficult experimental study in which patients who have experienced strokes
were experimentally provided with a positioning protocol for their upper
extremities in order to determine whether such additional intervention would
affect positively the normal range of motion in the defective limbs. Although
few differences were found between the control and experimental subjects, a
serendipitous finding was that the incidence of decubiti was noticeably lower
among patients in the experimental group.
Studies to facilitate the successful utilization of new technological develop-
ments in patient care
It has recently become possible to produce large quantitites of a lactose-
free liquid diet which is otherwise similar to the milk-based diets which are
generally given to naso-gastric tube fed patients. Nurse researchers utilizing
this technological advance, have demonstrated in a double blind study that the
elimination of lactose from liquid diets used for such surgical and post trauma
patients significantly reduces the indicence of diarrhea and gastro intestinal
25
disturbances otherwise common in this group. This study is now being replicated
in three states, and report of the findings of the first study are already
having effects on patient care and comfort. Even more importantly, these
studies have led to new views of lactose deficiency and lactose tolerance
tests which are likely to have widespread clinical ramifications.
Studies of effective intervention in community mental health settings and crisis
centers
A nurse researcher at Boston University is relating hospital-induced stress
as well as life stress in general to illness outcomes such as length of stay,
incidence of complication, and the use of pain medication with patients through
a measurement index of life stress that may be predictive of impending illness.
Studies to facilitate the successful application of new knowledge to patient
care
Unique studies by a nurse researcher at the University of Rochester have
combined the development of new knowledge with the simultane'Ous testing of its
clinical application. These studies were designed to develop improved nursing
measures to assist individuals recovering from a stroke to reach and maintain
maximum functional control of jaw and hand movements. In order to accomplish
this goal, a basic neurophysiological study involving monkeys was conducted
to determine the exact location and relative importance of cortical neurons
related to jaw movements. The normal range of neural control of jaw and hand
movements were identified in both monkeys and human subjects. Subsequently,
individuals recovering from a stroke participated in a similar study in order
to describe the effects of a stroke on these movements. As a result of these
studies, specific techniques are now being developed and tested relative to the
recovery and maintenance of eating and grasping following a stroke.
26
CURRENT FEDERAL ORGANIZATION AND SUPPORT FOR CLINICAL NURSING RESEARCH
The need for nursing research was recognized by NIH as early as 1955
with the establishment of programs for nursing research grants and for the
training of nurse researchers. A study section was created at NIH at that
time, and funds were earmarked for both programs. Currently, the program
is under the aegis of the Division of Nursing, a component of the Bureau of
Health Manpower, Health Resources Administration, the federal focus for
nursing in the federal government, and in which agency it is linked to
programs of nursing education, nursing manpower resources, and nursing
practice.
Although activities with relevance to nursing research are implicit in
various other components of the federal government, such as the Administration
on Aging, the National Center for health Services Research, and the National
Institute of Child Health and Human Development, the focus of nursing research
is centered in the Division of Nurs.ing.
There is coordination and coo[)eration between the nursing research program
and the other research programs in the federal government, espeicially those in
the National Institutes of Health, and the National Center for Health Services
Research. Applications which are of interest to two programs, such as a
cardiac rehabilitation proposal, are frequently given a dual assignment,
for example to the Division of Nursing and to the National Heart and Lung
Institute; this means that the proposal would be reviewed at the Council
level by the National Heart and Lung Institute and by the Division of Nursing.
Scientific review in such cases of dual assignment would be by the most
appropriate study section, as determined by the Division of Research Grants.
27
The program has grown and it has had an impact upon the nursing
community both through the support of research and through the education
of some 600 individuals prepared at the doctoral level to do research.
During this period a distinct change has been observable in the nature of
research accomplished. Early preoccupation with the study of the profession
has given way to a clear ascendency of studies related to the processes
involved in patient care provision. Particularly during the last decade
the program has supported research in clinical therapy.
In 1963, the Surgeon General's Consultant Group on Nursing was appointed
and charged with the task of advising the Surgeon General on nursing needs
and identifying the appropriate role of the federal government in assuring
adequate nursing services in the nation. This group strongly supported
nursing research and recoimiended that funds for extramural research in nursing
should be substantially increased to provide for a larger number of research
grants and for more varied types of investigations.
The nursing research program in the Division of Nursing grew steadily
until 1968 when appropriations levtsled off. Increasing numbers of well-
prepared investigators, however, ar-e now prepared to submit sound applications
for research in important practice areas.
There is need to broaden the :;cope of discrete nursing research projects,
to provide increasing support for institutional research development, and
to provide for replication of quality studies which show high promise for
inmediate impact on patient care, as well as for efforts aimed at dissemination
and utilization of findings for such studies, in order to put nursing research
to work in the improvement of nursing practice. The intramural research program
28
of the Division of Nursing has also been of importance in providing a
balanced program of nursing research.
Congress has consistently recognized the importance of programs in
nursing research and has acted upon this recognition by continuing to add
funds to the budget when none was requested by the Administration.
Administrative and dollar support are essential to such programs, linking the
laboratory and the patient care system. The community of health care
professionals cannot afford to lose any of the momentum that has been
created in the last 20 years through federal support of nursing research
and through the training of nurse researchers, and we feel that these
programs must be included in any long-range recommendations this panel
will make.
RESOURCES NEEDED FOR CLINICAL NURSING RESEARCH
In the past national efforts directed toward study in basic biomedical
research have led to significant achievements. Concentrated programs in
categorical research conducted at NIH have been extremely successful in
controlling disease. Continuing programs in biomedical research with their
present emphasis is necessary if the knowledge base of basic science is to
provide support for new focuses and dimensions in health care. However, it
is now time to recognize that by utilizing the knowledge developed in these
strong and concentrated programs in biomedical research, in conjunction with
some of the beginning knowledge of behavioral research, clinical sciences
are now able to address the problems related to health care. Nurse researchers
will contribute significantly to this new dimension in the study of health care.
29
Clinical researchers including nurse researchers feel it is necessary,
in light of current national concerns and needs, that the federal conduct,
support, policies and management of biomedical research be broadened and that
in addition the problems of health care delivery, health care maintenance
and prevention of disease be addressed through support of clinical sciences.
The supply of clinical researchers is also critical. It is necessary
for health professionals in the basic sciences to understand that doctoral
study is post professional training in most of the clinical sciences. While
the development of sophisticated knowledge is a function of post-doctoral
training in the basic sciences, in most clinical sciences pre-do ctoral training
has this comparable function.
The supply of clinical researchers is of particular concern to nursing.
In 1972 there v;ere 1,106 nurses who had earned doctorates in the United States.
This represents approximately 0.2 percent of all employed registered nurses
in this country. Since 1972 approximately 100 additional nurses have received
doctorates each year. In recent ye^ars approximately half of nurses earning
doctorates have received some federal assistance during their doctoral
studies. There is, however, an ev(;n greater interest on the part of many
nurses to pursue further doctoral -raining should funds become available.
Between January, 1973, and April, 1975, the Division of Nursing, DHEW,
received more than 1,000 inquiries from nurses desiring doctoral study.
We have appreciated the opportunity to appear before the panel. We
will respond to any questions you may have and we look forward to further
dialogue concerning these areas of mutual interest.
EMSrdy
9-4-75
30
Supplemental Statement of the American Nurses' Association - October, 1975
In testimony before the President's Panel on Biomedical and Behavicral
Research on September 30, 1975, the ANA Commission on Nursing Research
described:
1. the nature and diversity of current research
in nursing
2. the uniqueness of the questions being investigated
by nurse researchers who are doctorally prepared to
carry out health care research
3. the importance of the research being done by nurse
researchers in the improvement of health care.
During the question period follov/ing our testimony the Panel requested
further written supplemental testimony and recommendations concerning:
The lack of funding for and understanding of care-
oriented as contrasted with cure-oriented clinical
research.
The preparation of nurse researchers and the
importance of nursing education for the kinds
of research cited.
Research utilization by nurses.
In our verbal testimony we urged the need for further funding and
greater emphasis on the support of studies to reduce the complications of
hospitalization and surgery, and also studies to improve the outlook of
high risk groups such as premature infants and the elderly. Each of these
areas as well as those addressed in our earlier written testimony has great
potential for enhancing the quality of life and for reducing the costs of
health care through improved methods of prevention, rehabilitation and
patient education. Therefore, the following recommendations in relation
to the above problems are being made to the Panel by the Commission on
Nursing Research of the American Nurses' Association.
31
Problems Related to the Lack of Funding for and Understanding of Car e-
Oriented as Contrasted vn'th Cure-Oriented Clinical Research
Substantial federal financial support for nurse researchers is
justified by the grovn"ng demand for improved health care accompanied by
concern for cost-effectiveness. Support for research in nursing from
the major institutes of NIH has been minimal since their priorities have
most often been oriented to the disease-cure continum, and have less often
been directed toward the improvement of preventive methods or toward the
reduction of complications, and improvement of quality of care in the
chronically ill. Nurses are engaged in many areas of research which are
leading to better methods of care, for example in the areas of pain
alleviation, care of burned patients, home care during dialysis or
parenteral nutrition, management of dying patients, and identification
of factors contributing to child abuse.
To date the funding made available for such studies has primarily been
through the Division of Nursing of the Health Resources Administration.
Last year only minimal funds were available to cover research in nursing
practice and patient care and for institutional grants for research
development which are essential to the development of the current potential
of this area of research in health care. We have projected that the needs
for future funding based on the past history as well as public demand for
improvement in patient care will require significant increases in this
support.
This would require significant increases over previous budgets, however,
it is certain that the improvement in health care and reduction in cost of
this care will make this investiment one of the most cost-effective programs
of the HEW budget. We urge that specific funds be designated as line items
32
in health related budgets with the recognition that nursing research is
an important item in the budgetary planning of both Congress and the
Administration.
Recommendation
SOME PROVISION SHOULD BE MADE FOR THE CONDUCT OF CARE-ORIENTED RESEARCH IN
EACH OF THE CURRENT PRESENT INSTITUTES AND BUREAUS, TO COMPLEMENT THEIR
FOCUS ON CURE-ORIENTED RESEARCH
The problems of health care delivery, health care maintenance and
prevention of disease must receive greater emphasis and support. Funds
should be available to nurses or other clinician groups involved in care-
oriented research. Nursing research should be visible in the federal
sector. Also, there should be close contact among those persons in DHEW
responsible for research training programs for nurses, nursing research
programs and programs related to the general field of nursing.
Problems Related to Nurse Researchers
A major problem is the small number of nurses prepared to conduct
research. In 1972 there v/ere 1,105 nurses who had earned doctorates in the
United States. This represents approximately 0.2 per cent of all employed
registered nurses in this country. Since 1972 approximately 100 additional
nurses have received doctorates each year. A recent survey of nurses v/ith
doctorates reported that only 31.5 per cent of these nurses are engaged in
research. The majority are employed in educational settings, where they
teach or administer programs.
Recommendation
FEDERAL FUNDS SHOULD BE MADE AVAILABLE FOR THE SUPPORT OF PRE-DOCTORAL
TRAINING FOR NURSES
In order to increase the supply of nurses prepared to do research, it
is necessary to enlarge the pool of doctorally prepared nurses. In recent
years approximately half of nurses earning doctorates have received some
33
federal assistance furing their doctoral studies. There is a great interest
on the part of many nurses to pursue doctoral training should funds become
available. Between January, 1973, and April, 1975, the Division of Nursing,
DHEW, received more than 1,000 inquiries from nurses desiring doctoral study.
Recommendation
RESEARCH DEVELOPMENT PROGRAMS SHOULD BE SUPPORTED IN ORDER TO DEVELOP THE
NURSING RESEARCH CAPABILITY OF INSTITUTIONS AND GROUPS OF NURSING FACULTY
The care issues of the practice of nursing have led nurses with research
training to return to the clinical area after they have completed their
preparation in research. The choices of clinical research field problems
made by nurse investigators are largely cure-oriented. Therefore, the
use of general institutional resources for research, including research funds
already available through existing programs, should be made available to young
investigators who need to work under these senior research colleagues. This
mechanism for advanced study is needed in the clinical sciences just as it
is in other fields. Institutional and other grant funds should also be
available for pilot research efforts for these beginning investigators.
In addition, because of the clinical nature of this research there is a
need for greater stability in research funding. At present it is very
difficult to carry out a study which involves for example long term effects
if early environmental manipulation when the longest periods of funding
tend to be around five years. Often current review methods require a major
research effort to be closed completely on very short notice. These conditions
are detrimental to clinical areas of research.
3'*
Recorrimendation
SEVERAL NURSING RESEARCH CENTERS SHOULD BE ESTABLISHED IN CAREFULLY SELECTED
SETTINGS TO INCREASE THE QUALITY AND QUANTITY OF CLINICAL NURSING RESEARCH
If the care of patients is to be based on new fundamental knew! edge for
improved techniques in nursing practice, research centers for the continued
development of such knowledge are needed in nursing just as they are all
clinical sciences. National nursing research centers for research and
training, geographically distributed, would provide facilities available
throughout the nation not only for intensive research and study by nurse
investigators but also for the education of expert professional practitioners.
These centers would conduct clinical research in nursing science and nursing
practice as it relates to the health care of people. The research centers
would provide a comprehensive approach to the clinical science of nursing
which is necessary to promote understanding of the many factors in health
care and to stimulate the development of new approaches and techniques for
solving health care problems. There has been no previous support for nursing
research centers.
Recommendation
STUDY PANELS AND COUNCILS WHICH REVIEW AND MAKE DECISIONS ABOUT THE APPROVAL
AND FUNDING OF BIOMEDICAL AND BEHAVIORAL RESEARCH SHOULD INCLUDE NURSE
RESEARCHERS
Problems in Research Utilization
There is a gap in nursing as in other disciplines in the speed with
which research findings are put into practice. While the support of
demonstration and utilization projects should not be allowed to detract
from the conduct of basic research, there is need to develop mechanisms through
which research findings can be more efficiently and quickly put into practice.
35
Recommendation
PROGRAMS AND MECHANISMS SHOULD BE DEVELOPED WHICH ARE FOCUSED SPECIFICALLY
on RELATING BASIC RESEARCH PROGRAMS CONDUCTED WITHIN THE DHEW TO PRACTICE
SETTINGS IN WHICH SUCH FINDINGS ARE USED
In the past national efforts directed toward study in basic bioinedical
and behavioral research have led to significant achievements. Continuing
programs in biomedical research with their present emphasis is necessary if
the knowledge base of basic science is to provide support for new focuses and
dimensions in health care. By utilizing the knowledge developed in these
strong and concentrated programs in biomedical research in conjunction with
knowledge in behavioral research we are now able to address many of the
problems related to health care. Nurse researchers can contribute significantly
to this new dimension in the study of health care.
We also wish to support recommendation #2 in the Statement by Representatives
of the Councils of the National Institutes of Health to this Panel. We are
particularly in agreement with Parts 1 and 2 of this recommendation which
state:
1. the NIH has authority and responsibility to maintain
that level of basic and applied biomedical research
capacity necessary to meet the expectations of the
American people:
2. the NIH has authority and responsibility to provide
for and facilitate the transfer of research knowledge
to general utilization and for bringing the problems
faced by practitioners to the attention of biomedical
investigators.*
*Statement of the Representatives of the Councils of NIH to the President's
Biomedical Research Panel, Charles C. Sprague, Chairman, Recommendation #2, p 15,
September 30, 1975
36
We hope that the testimony and statements of the ANA Commission on
Nursing Research before the Panel have been informative and have promoted
an understanding of research in nursing and its potential for impact on the
health care of the American people. We hope our position will be included
in the Panel's report as an research area of importance to health care and
of promise for productive future research.
AMERICAN NURSES' ASSOCIATION
COMMISSION ON NURSING RESEARCH
EMS:dy
10-17-75
37
JUDD MARMOR, M.D., Pmident. UnivenitY of Southem California School
of Medicine, 2025 Zonal Avenue. Lo» Angeles, CXifomie 90033
ROBERT W. GIBSON, M.D., President-Elect, The Sheppard & Enoch Pratt
Hospital, Towson, Maryland 21 204
DANIEL X. FREEDMAN, M.D., Vice-President. University of Chicago, 950
East 59th Street, Chicago, Illinois 60637
JACK A. WOLFORO, M.D., Vice-President, Western Psychiatric Institute and
Clinic. 381 1 OHara Street, Pittstxirgh, Pennsylvania 15261
JULES H. MASSERMAN, M.D., Secretary, 8 South Michigan Avenue,
Chicago, Illinois 60603
JACK WEINBERG, M.D., Treasurer, Illinois Slate Psychiatric Institute, 1601
West Taylor Street, Chicago, Illinois 60612
FRANCIS J. BRACELAND, M.D., Editor, American Journal of Psychiatry,
1700 18th Street, N.W., Washington, D.C. 20009
HON. WARREN E. MAGEE.teffs/ Counse/, Riddell Building. Suite 308, 1730
K Street, N.W.. Washington, D.C. 20006
MelvinSabshin.M.O.
Medical Director
Donald W. Hammersley, M.D.
Deputy Medical Director
Jeanne Spurlock. M.D.
Deputy Medical Director
Henry H. Work, M.D.
Deputy Medical Director
Jack W. White. D.B A.. Deputy
Director, Business Administration
■IGHTEENTH STREET NW WASHINGTON DC 20009
PHONE: AREA CODE 202—232-7878
August 18, 1975
Richard T. Louttit
Staff Director
Department of HEW
Suite 3100
2401 E, Street, N.W.
Washington, D. C. 2 0506
Dear Mr. Louttit:
Dr. Melvin Sabshin has asked me to respond to your letter
of August 12th concerning testimony for the President's Biomedical
Research panel.
Dr. Sabshin will be most pleased to appear before this panel
and discuss the stand of the American Psychiatric Association
on this critical subject.
For years the American Psychiatric Association has been on
record as a very strong supporter of research in the whole area of
the medical-psychological aspects of behavior and its biological
underpinnings .
On June 24th of the year we presented testimony before the
Senate Subcommittee on Appropriations for Labor, Health, Education
and Welfare. In this presentation we noted that the House had only
met the comparable fiscal 1975 appropriation for mental health
research and further commented that this meant in effect that
efforts in mental health research will have to be diminished in
fiscal 1976 because of inflation.
We had stated in our House testimony that "per year under
current care for heart disease and cancer we spent $250 per patient
for research, and for mental illness, $20 per patient under care."
It was the strongly worded comment of our officers testifying, that
mental illness is just as devastating in its effects as heart disease
or cancer, and therefore must be given more than token support. It
has continually been our stand that efforts in mental health research
39 . '
Richard T. Louttit
August 18, 1975
Page Two
are productive, having accomplished dramatic breakthroughs in the
treatment of depression and psychoses with a promise of more to
come.
A particular current research concern of our organization
includes developments in determining the genetic bases for
schizophrenia, new relationships between brain and behavior, and
better understanding of the biochemistry of neural activity.
A major concern of the APA at this time is that we are moving
backwards and not forward in our research efforts. In fiscal
1975 one million dollars less was appropriated for this effort
than in fiscal 1971. We therefore recommended the level of $105
million dollars for mental health research to continue the work
that is ongoing and to provide a few new starts. (Our testimony
noted that the National Coalition for Health Funding had recommended
$100.2 million as a minim\im figure for this purpose.)
It is equally our concern that manpower in the total area
of mental health activity and particularly in the area of mental
health research needs to be strengthened. Besides the money spent
directly on research, money spent for manpower training will enhance
the capacity of individuals not only to enter the field of research
but to carry out the research needs that are so much a matter of
concern. A chart which we presented at the hearings graphically
demonstrates some of the difficulties we face as the dollars for
research diminish.
During June of this year we assembled a major conference
under the direction of Dr. Ewald Busse to discuss the education
of Psychiatrists. One section of this concerned the status and
function of research in psychiatry and the education of psychiatrists
for research. A copy of this preparatory material is attached.
This subject was discussed extensively during the conference. The
proceedings of the conference are not yet available, but it is
obvious that considerable attention will be devoted to the research
topic.
Because of our longstanding interest in research as a background
for training and service in the mental health field, we welcome the
opportunity to present our views and Dr. Sabshin looks forward to
appearing before your panel on September 30.
Sincerely,
cd^
Henry H.^Work, M.D.
Deputy Medical Director
Professional Affairs
HHVJ/em
cc: Dr. Sabshin ^° . ,.
STATUS AND FUNCTION OF RESEARCH IN PSYCHIATRY AND THE
EDUCATION OF PSYCHIATRISTS FOR RESEARCH
Introduction
While still gathering ancillary supporting documents, the Committee herein
reviews: (a) the functional links of research to professional activity and
societyj (b) sources of strain and the general status of research and research
careers in psychiatry and definitions of research activities and researchers;
(c) general goals of education of psychiatric residents in research and their
implementation; (d) training for career research specialists; (e) implementing
mechanisms for support of research training, including issues of sites of train-
ing, support, and recruitment.
Hard data for many of these issues is lacking because of insufficient focus
on the problem in the past. Because of this and the nature of some of the prob-
lems and solutions, the general approach will be to identify issues and options
when relevant.
A.: THE FUNCTIONAL LINKS OF RESEARCH TO PROFESSIONAL ACTIVITY AND SOCIETY
a) The role of research in professional activities .
The importance of research to the authenticity and integrity of professional
activity should need little elaboration. Research is both a stimulus to profes-
sional thought and one mode of approach to action. The scientific underpinnings
of clinical practice are now key to the social sanction granted the physician,
although such scientific knowledge is incomplete and imperfect. Thus there is
also a close relationship between clinical practice, scholarship and the develop-
ment of new knowledge. This is the hallmark of modem medicine.
Such statements unfortunately have the tone of sermonizing, perhaps because
of the intrinsic difficulty in conveying (and sustaining) the process of arriving
at answers that not only pose new problems, are not only unpredictable and often
surprising, but--most crucial ly--independent of the personal wishes and popular
demands of the moment. This process, while tapping basic personal drives of mas-
tery and curiosity, and involving the poorly understood psychology of creativity,
is rooted in and affected by sanctioning social institutions, values and systems.
Whether or not research is valued, and how it is, not only describes the character
and quality of a profession and its academic disciplines, but also the values of
the individuals and institutions to which they are related.
Agencies, institutions and societies that invest in the future may value not
only the products of research, but the sustaining processes peculiar to its special
nature. Research thus requires sustained rather than intermittent inquiry, even
though the motor at times appears to be "idling." Discontinuities in the requi-
site habits and skills vitiates access to and utilization of the evolving flow of
ideas and techniques which lies behind all 20th century scientific advances.
Essential to the activities of research and discovery are the rules of the
evidentiary process and plausible inference. This mode of proceeding often must
limit the immediate utility of scientific research; yet the scientific mode of
k]
thought and procedure characterizes the sequence of operations in good everyday
clinical practice--which also is intrinsically limited. The latter carries
with it the obligation to apply knowledge to the individual case and to act (or
deliberately not act) very often in the presence of half knowledge on behalf of
(and with the consent of) the individual. The research process is characterized
by the search for new information on behalf of authentic knowledge about "the
way things are," and in the absence of absolute certainty as to its outcome or
applicability and with the consent of supporting institutions and value systems.
The commonalities, the interchange between these two modes of operating in
scientific medicine, and sometimes the strains, are obvious. But both research
and clinical practice involve a similar restraining discipline: a degree of
uncertainty as to means and outcome and an inability necessarily to gratify
explicit demands from sponsors or consumers for a specific outcome.
Nevertheless, valued specific outcomes in medicine or science require the
process of research. The aggregate impact of discovery and the scientific activ-
ity provides increasingly powerful means by which man and his institutions may
understand and shape their destiny. This growth of knowledge also imposes an
increasing collaboration and concern of all affected.
Thus knowledge and discovery, engendered and evaluated by scientific research,
begins with partial knowledge and admits ignorance. Research will provide often
imperfect guides for the present and unpredictable ones for the future. The uses
and utilization of research require judgment and shared accountabilities. And
a fundamental respect for these facts is indispensible to scientifically and
ethically based daily practices and judgments of clinical medicine.
b) Research as a component of a system .
We view research as one of the several components of general professional
activity (1). As an attitude and as a practice, it impinges on preparatory and
special clinical education, as well as the continuing education of the psychi-
atrist. Increasingly research in psychiatry bears immediate relevance on clin-
ical practices. It affects and is affected by various forms of service delivery,
and is critical in the corraiiunicative networks associated with professional and
scientific work.
The interplay between clinical activity and service delivery and the knowl-
edge system is crucial. While physicians deliver care in the absence of complete
knowledge, they are expected to know the degree of scientifically established
certitude that can be asserted for their activities and the state of the arts
and sciences upon which they ultimately rely. This fundamentally requires asking
the "hows and whys" of specific clinical findings and interventions. The activ-
ities of research cannot occur in isolation from modern medical needs or practices.
We do not view research as either competitive with nor alien to concerns
for health delivery. What we stress is the need for a commonality and a community
of clinical practice and ideas out of which investigative activities are stimu-
lated and from which they gain their meaning and relevance. For this reason v/e
emphasize the need for clinicians and clinician investigators with special focus
on a problem area or diagnostic group--an enhancement not of guilds but of sub-
special ization--i .e. , of special effort in special areas. These may participate
in research, or conduct it or apply it. For the life of inquiry, an audience of
m
both researchers and consumers, of participating students and of generally and
specially informed practitioners is necessary.
We stress that discovery in a vacuum is useless, and that transactions among
the generations of teachers, colleagues, students and patients render findings
and ideas viable in the entire process of articulated training, service and
research. The knowledge engendered by research is communicated throughout a com-
munity comprised of investigators in the medical and biobehavloral sciences and
related professional groups; teachers and the next generation of students; those
delivering services to the mentally ill; patients, their families and their com-
munities; and planners formulating mental health policies and programs. These
are a part of the total fabric to which research activities are related.
c) Consequences of a systems view to research education objectives .
Our most general concern, then, is the advancement of a pattern of practices,
reflective thought, investigation and communication in psychiatry, and our focus
Is how all of this impinges on specific issues of psychiatric education. As we
discuss issues, we wish to keep them within the framework of this wide community
of participants and consumers who--with various gradations of emphasis--are linked
to those who specialize in research.
With respect to the educational relevance of research for every trainee, we
have no doubt that without the absorption of proper attitudes toward evaluating
his clinical work and the state of knowledge in his field, and without the abil-
ity to utilize the results of observations, the future psychiatrist will have a
distorted view of fact and opinion; his tendency will be to solve problems by
rationalizing or by retreat to doctrine. Without an emphasis on the research
attitudes of critical review of data and admission of ignorance, the clinical
psychiatrist would not be competent to evaluate the quality of treatment or the
care of programs to which he is related, nor would he be able to judge his own
work critically, let alone the findings of others. Without this general emphasis,
clinical innovation in health delivery and practice would become little more than
ritual and tribal rites, and cultist doctrine.
It is apparent that it is in the public interest for society to support the
acquisition of reliable data about the nature of man and his dysfunctions and for
the consumers--and all clinicians--to be educated as to how this continuing and
sustaining process in fact occurs. At the very least, of course, It requires a
replenishing supply of personnel capable of inquiry at a variety of different
levels relevant to the field of psychiatry and to the structure of knowledge in
the life sciences. This means general education as well as the bringing of new
talent into the research subculture. Production of research will be enhanced with
the development of clinicians with special areas of focus. The entire enterprise
represents an investment in the future and an ability to adapt to future needs
and findings.
B.: THE CURRENT STATUS OF RESEARCH AND RESEARCH CAREERS IN PSYCHIATRY
Introduction
Research training rests fundamentally on ongoing and active research.
Psychiatric research, in turn, is clearly linked to the structure of knowledge
h3
and theory in the life sciences, and, in part, to problems posed by the clinician.
The past 25 years has seen a marked acceleration of basic and clinical science
investigations, andnew knowledge, as well as new therapeutic agents, and an
approximate five-fold increase of clinical psychiatrists to utilize this. New
sciences also have emerged, as have new patterns of clinical investigations both
of clinical dysfunctions and the mechanism of action of therapies.
But 25 years is a brief time within which to securely root the tradition of
research training, supply that gradient of expertise which is intrinsic to it,
and disseminate not only the knowledge, but the personnel, methods, equipment and
technologies either to the sites of training or of practice in numbers sufficient
to provide any critical mass. This critical mass is required to sustain and gen-
erate this momentum. A 1970 survey found only 340 psychiatrists reporting 40%
or more of time devoted to research (2).
In terms of manpower sufficiently skilled to bring a significant focus of
attention upon inquiry, psychiatry may now be where internal medicine was shortly
after World War II. Yet psychiatric research training and research programs are
usually lumped with the more highly developed clinical sciences by bureaucrats
or legislators concerned with health policy. Psychiatry—and its underpinnings
of knowledge--has also received more than its share of the current anti-intellec-
tualism. The prevalent ahistorical attitude provides no perspective on the
advance of psychiatry from the era of the all-purpose alienist to the increasingly
differentiated community of general and subspecialists which the profession is now
capable of providing if it can move forward and, with some period of stability
and support, articulate its components. Any phase out of the recent (i.e., past
25 years) momentum is, then, for psychiatry most untimely and retrogressive.
a) Brief assessment of current status of psychiatric research .
The history of the development of research in psychiatry is not yet system-
atically documented. Our assessment is that it has been a rapidly accelerating
and powerful activity, increasingly productive and now emerqing as consequential
to the clinical decision-making process.
This development has occurred against the background of: 1) a rapid expan-
sion since 1946 from approximately 4,000 to 25,000 M.D. practitioners and a recent
beginning of authentic subspecialization in psychiatry; 2) psychiatric activities
in sites in which biomedical sciences are developed--such as medical schools or
general hospitals as sites of teaching, training and consultation; 3) the Veterans
Administration, with a 30-year-old investment in services, research and training
linked to university centers; 4) research investments by state departments of
mental health in various state hospitals or in special units and institutes; 5)
from 1950 to 1962, a collection of remarkable scientific leadership within the
intramural programs of the NIMH (linked to the biobehavioral and medical sciences
of the NIH), and since then the emergence of a small active cadre of productive
younger leading investigators; 6) explicit focus on the training of career research
manpower (NIMH Research Career Programs [3]); 7) the remarkable growth accelerat-
ing in the late 50's of a range of allied professionals working with behavioral
dysfunctions and in basic research which has been partially related to them; 8) a
variety of inter-relationships and growing relevance of other cognate disciplines
in the biosocial sciences, and the emergence of new disciplines such as psycho-
pharmacology and neurobiology. Such developments have created both a critical
mass of knowledge generating and consuming manpower and new and deeper structures
kk
of knowledge. This evolution, while encountering increasingly severe and dan-
gerous strains (see Section B, subsections [c] and [d]), has also occurred so
rapidly that the consequences are as yet difficult to assess in perspective.
It would not be possible or appropriate to identify each of the cognate dis-
ciplines or relevant research problem areas in an attempt at an overall "state
of the art" review of psychiatric research. Such an effort recently was under-
taken by NIMH; the labor consumed over a year-and-a-half of intensive sustained
intramural time of numerous scientific personnel, with the additional aid of
staff and a wide body of outside consultants. The results can be considered only
an initial attempt to pull together an overview and is designed as a report to
the Director of the NIMH.
The NIMH effort merely re-emphasizes a theme the Commission has identified:
the pressing need to articulate and assess the broadening bases of knowledge,
information and methods relevant to the questions that psychiatry attempts to
comprehend.
1) Trends in clinical research . Certain trends are obvious: an increasingly
problem-centered and evidentiary emphasis in psychiatric research; a new focus on
diagnosis, differential diagnosis, and the validity and reliability of different
diagnostic criteria; the construction and testing of inclusionary and exclusionary
criteria for diagnosis; the use of outcome, follow-up, therapeutic response,
developmental history, family history, and cross-cultural studies for these pur-
poses. The body of emerging data have been designed to delineate familial patterns
in diagnostic groups as well as special studies (e.g., cross-rearing) of genetic
determinants of the major mental disorders. This research accelerating in the past
decade returns to some of the roots of psychiatric research, to some of its begin-
nings in naturalistic observation, but utilizes advanced techniques and designs
sufficient to provide discourse among groups of investigations and investigate".
It thus marks an authentic momentum.
2) Trends in neurobehavioral sciences . Advances in the brain sciences, in
neurochemistry and psychopharmacology have perhaps captured more attention than
other developments, but nevertheless are of central importance to emerging
research developments and of relevance to descriptive and therapeutic aspects of
psychiatry. Such developments also emphasize the link of the basic biobehavioral
and life sciences to psychiatry. The momentum in neurobiology occurred both by
the work of psychiatrists who had problems of behavior disorder ultimately in mind,
and by basic scientists who were in pursuit of other questions but found their
discoveries also relevant to the field of psychiatry. Numerous false gropings
and probings of the past have been identified.
But most importantly, a powerful logic, based on recently identified neuro-
biological findings, has emerged to guide psychiatric research in biological
mechanisms. We have in mind basic knowledge of neurohumoral mechanisms in nerve
transmission, the role of certain enzymes as receptors and messengers in the
transmission processes and various feedback systems for the control of neural
excitability and biochemical events; the delineation of the action of pituitary-
adrenal hormones in the central nervous system; the identification of neuronal
pathways specific to specific biogenic amines and beginning grasp of their role
in sleep and behavior. These, and the discovery of other basic mechanisms,
spurred in part by a search for the mode of action of clinically effective psycho-
tropic drugs, have in turn provided an array of measures in clinical populations
that promise to distinguish distinct subtypes of psychobiological states in mental
disorders. Thus enzymes (e.g., MAO, dopamine beta oxidase, COMT) can be measured
in the periphery (blood, urine and CSF), as well as the patterns of the concentration
^5
of substrates (e.g., norepinephrine) and metabolites (e.g., MHPG) ; these, in turn,
may usefully reflect central events.
The identification of new neural systemS'-biochemical nervous system — and
increasing knowledge of the role of extrapyramidal systems and new knowledge of
the role of dopamine in limbic and cerebral cortex, has helped to open new ques-
tions about the mechanism of action of psychotropic drugs and the organization of
CNS systems in a range of behaviors. With the aid of computers, implanted elec-
trode techniques in animals, and the growing expertise in designing behavioral
tests that can more sharply link psychological events with electrical and biochem-
ical measurements, a range of peripheral psychophysiological measures can now be
more confidently correlated with known central events derived from animal research.
Thus spikes governing REM sleep onset (discovered in animals) have a correlate in
treasures made from the surface of the periorbital muscles; the case is similar
for various electrical measures detected from the scalp and analyzed with the aid
of computers. Recent studies indicate the importance of laterality to certain
mental functions, and this has been rationally applied to unilateral ECT therapies
in order to diminish side effects on memory.
The point is that the mechanisms of peripheral biochemical and electrophysio-
logical measurements can be more securely based on known internal CNS processes
and the validity of measurements in use has remarkably increased in specificity
and power.
3) Psychosocial and health delivery research . There is a lively concern-
expressed Krthe~orTgTnaT~"cHargenby~th^ the need to develop
social, cultural and personality approaches to disordered behavior. It should be
noted that the roots of progress in so doing are quite apparent, while a conse-
quential focus Is yet perhaps to be seen.
Thus there are the landmark studies of the 1950's of the incidence and preva-
lence of mental dysfunction and distress and indications of the differential role
of social class. (Methods of studying small group behavior which originated from
sociological and social psychological research become applicable to studies of
family and therapeutic milieu interactions; conmuni cation patterns and cognitive
styles [and differentiated thought disorders] can be directly studied in family-
patient interactions and certain cross-cultural similarities in families with
schizophrenic offspring have been reported.) There are developments from this
leading to new neighborhood and community based studies of the evolution of symp-
tomatology as a total population of the conmuni ty's children are followed over a
period of years; such studies investigate the link of different familial structures
to the child's developmental progress and deviations, to his ability to adapt, to
develop cognitive skills, and the relative dependence and independence of symptom
formation with respect to these parameters.
New tools, interests, energy and computer techniques link the areas of per-
sonality, social structure and cognitive development. Nutritional and social-
cultural deprivation in early development show marked though varying consequences;
in recent follow-up studies (in Guatemala by Kagan et al.), new data on resilience
and compensatory adaptation in latency and early adolescence are evident. Animal
models of various early deprivations (e.g., of peer or mothering contact) also
provide a broadening base for the disciplines of developmental psychology and for
studies of the role of specific patterns of communicative behavior and small group
behavior on coping mechanisms and vulnerabilities. The area of stress and change
has similarly begun to advance; some such studies raise the question of whether
social class per se, or stage in the life cycle, or the rate of change of problems
to be adapted to, are more closely linked with the intensity of symptoms in mal-
adaptation.
he
Thus, while there is a perceived lack of direction of a well-defined pattern
in socio-cultural research, there is at the same time a utilization of hints and
findings from the past and a much broader base of approaches and interchange among
disciplines. No doubt, untutored clamor (rather than planning) for research in
these areas stems from alarmingly rapid social change and areas of chaos in urban
centers with which psychiatrists are poignantly in touch and relatively helpless.
The need for evaluation, for the development of public health planning, of
course has to be acknowledged. In so doing, the relative lack of skills far beyond
the grasp of psychiatry--deficiencies in economic analysis, or the disciplines of
political science, sociology and public administration— are also accountable for
perceived lags. Nevertheless, improved case-finding techniques and use of epi-
demiological tools, multi-dimensional designs for inquiry in the field with better
input of psychiatrically relevant questions in surveys, are being applied with
such questions as the utilization of services in mind. The differentiation of
social class or symptomatology as a unitary variable in utilization has begun--
factors such as relative psychosocial isolation may transcend either social class
or symptoms in the utilization of mental health services, for example. The use
of matrix and systems management designs for deploying manpower and defining prob-
lems is being tested for policy and intervention purposes.
It is important to stress that the characteristics of the mental health deliv-
ery system, a task oriented program working with ill -defined objectives under heavy
work overload conditions, tend to work against research values. Individuals with
heavy clinical work loads do not have the time to reflect on problems and these
individuals tend to regard the investigation as a luxury. Those who must try to
solve problems that are poorly formulated cannot afford the skepticism that seems
essential for the true researcher. Busy clinicians adopt rules of thumb and con-
ceptual models that seem to them to work, and then do not always go through the
empirical procedures that would test these assumptions. We must note as we make
this brief assessment of psychiatric research that the effort to develop research
and research training in this clinical setting have encountered difficulties. The
factors that have impeded the development of psychiatric research are not only the
difficulty of the problems faced, and the limitations in resources. They also
include characteristics of the subculture of psychiatrists. Thus, in general, we
see a rapid development that has gone largely unappreciated, but a very thin cadre
of psychiatric researchers. We see the entire field poised precariously as blanket
policies affecting research manpower overlook the flourishing but still young devel-
opment of psychiatric research. Practice can also be set back if our stage of
development is not strongly asserted.
4) Research relevance to clinical practice . Research in psychiatry now
means that the clinician delivering the best of care must attend to differential
diagnostic criteria as the basis for selecting drugs of choice and for anticipating
and evaluating and treating their side effects. Physicians must now be able to
formulate a practical plan for treating a person with a diagnosis, for referring
or deploying social, family and group therapies and support and reinforcements in
helping the individual gain control over his dysfunctions and maximizing reinforce-
ments in the social context in which this must occur. The growing awareness of
subcultural differences renders the clinician far more sensitive to the meaning of
specific behaviors and alert to the task of functionally analyzing the specific
psychiatric reference of conmuni cations, symptoms and behaviors in a given subculture.
Given advances in neurobiology, the clinician has some background as to what
neural and chemical systems and dysfunctions in them may be underlying differential
drug response as well as side effects of drugs. The role, for example, of dopamine
receptors in schizophrenia and as the basis for anti -psychotic drug action, or
47
their role in Parkinsonian side effects, as v/ell as the balance of central cholin-
ergic, serotonergic or noradrenergic systems, is increasingly inferable through
measures of urinary metabolites or drug response. It is already evident that dif-
ferent neurochemical status may mandate different therapies--e.g., in unipolar
depressions— and that markers for these conditions will be increasingly available
within a few years.
The point is that on behalf of excellent patient care, the clinician has rea-
son to be more attentive to as well as contributory to research advances. There
is a growing ability to focus at the same time both on diagnosis and on the
individual's specific problems. Coupled with the observational and evidentiary
basis for assertions in clinical psychiatry, these developments tend to close the
gap between everyday practices and research advances.
In the conceptual area we have come to a kind of understanding of the mechan-
ism of action of pharmacotherapeutic agents and the similarities or differences
in patient response that provide a useful bridge between rapidly evolving research
and equally rapid changes in clinical settings and modes of practice. The point
is that empirical findings --that such and such a drug has some use in schizophrenia-
are now backed by the knowledge of which biological systems can in fact be specif-
ically affected by these drugs, and this basic knowledge provides a framework with
which to better comprehend clinical data. Empirical findings on the utility of
supportive care in pharmacotherapy also help articulate and integrate two modes of
treatment. While not as yet directly relevant to action, the growing body of knowl-
edge on the familial clustering of symptoms and diagnoses in affective disorders
adds intellectual cogency to what might otherwise have been a routine family history-
taking.
5) Research of the future. Concomitant with this increasing relevance of
basic science and fundamental clinical research and the conceptual framework in
which these findings gain meaning, is the emergency of genuine new fields. We
refer, for example, to behavioral genetics, biochemical pharmacology, behavioral
biochemistry, developmental neurobiology. These have a methodological content and
central conceptual reality that is quite different than a collection of scientists
from different disciplines adding their views. Psychiatrists have aided in the
development of some of these new disciplines and psychiatric and NI^f^ sponsorship
has been crucial for some of them. Psychiatrists thus have acquired either col-
leagues with generic expertise in relevant biological, social and psychological
disciplines, or have acquired that expertise in their own right and have brought
it to bear upon issues of clinical importance.
While new disciplines have already emerged, others well may as boundaries are
exploited. This is evident in the use of knowledge on the structure and function
of the family and small groups; in the area of comnuni cations in group processes
and in studies of cognitive development; in the use of computer sciences applied
to psychiatric issues of diagnosis and recordkeeping— in brief, in the use of
sophisticated techniques applied to important issues of ultimate or proximal clin-
ical relevance.
There is clearly improved application of mathematical and statistical pro-
cedures to clinical issues (as in the study of the efficacy of various treatments);
progress is evident in the use of sophisticated behavioral techniques in the design
or animal or clinical studies in which psychophysiological measures or issues of
adaptation, learning and memory are being investigated. With such evolving appli-
cations and adaptations of techniques one can see new subject areas emerging in the
clinical area--clinical psychopharmacology, for example. Such evolving new dis-
ciplines encompass the interest of psychiatry and affect developments in psychiatric
research .
k8
These developments mandate en enhanced focus on psychiatric manpower and
organizations of research so that psychiatry can bring its problems to these new
techniques and bodies of knowledge. Any retreat is, in this context, a tragic
rout. The lack of a critical n^ass of expertise must, however, be noted. The
inability of many, sites of service or training congenial to the development of
research in fact to implement, adapt, utilize and revise this momentum, points to
a grave crisis facing psychiatric research and research careers in psychiatry.
The heritage of the sound investc.ent of the 50's end 60's can readily be dissi-
pated as federal support is systematically reduced.
Finally, in anticipating issues discussed below, we assert that the status
of psychiatric research requires special focus. The phase of development of
research manpower in psychiatry is such that the field is about where internal
rredicine was in 1950--a field just beginning to be able to produce subspecialists:
people who know, for example, more about depression or schizophrenia than the
general psychiatrist, and for whom subspecialty practice, research, research eval-
uation and knowledge are prime obligations. Psychiatry is just beginning to
develop a cadre of experienced investigators, of more junior and beginning investi-
gators linked to senior role nx)dels--the actual templates upon which a variety of
research careers are in fact built. The generalized attack on all research train-
ing has been most critical and untimely for psychiatry's future; rraany practices
of the NIH— not necessarily those of NIMH— were in fact criticized. The success
of the NIMH research career support contrasts markedly with that of other institutes,
6) The special problem of child psychiatry . Child psychiatry, with a later
academic start, has lagged behind adult psychiatry in all branches but especially
in research. Not only is there much less of it being done but what there is seems
more divorced from service and training activities. However, the pressure to
carry out investigations as an essential component of the academic function is cur-
rently being felt in university divisions of child psychiatry but the need is
externally rather than internally generated and relates to status rather than to
burning scientific curiosity. For this reason, questionnaire inquiries are more
indicative of wishful thinking then reality. In the most recent survey of thirty-
two divisions conducted by Sonis, twenty-nine claimed to have programs in clinical
research, twenty-one in developmental research, twelve in "operational" research,
and twelve in pharmaceutical research. This degree of activity is certainly not
reflected in research publications which are sparse and characterized, on the whole,
by lack of rigor and control. In actual fact, only two divisions have discreet
"research units stacked by trained investigators and supported through federal and
private. research funds, and only one of these has a discreet building devoted to
research and child psychiatry.
Again, to en even lesser extent than in adult psychiatry, is a propitious cli-
mate of research being festered end integrated into the training program. Research
concerns are crowded out frcn overloaded curricula and at some centers, research
preoccupations are even discouraged as detrimental to training in child psychiatry.
There is a feeling that the child might be hurt by research. The overprotection
of the patient is very characteristic of this discipline. There v/ould need to be
a radical reorientation of the training philosophy if research is ever to become
en integral part of the child psychiatrist's outlook and approach. At present, he
is even more service crier.ted than the adult psychiatrist and becoming more so as
community psychiatry grows.
There are, fortunately, Trojan horses within the camp. The Academy of Child
Psychiatry has en active rese;rch cor^ittee v/hich is attempting to spread its
enthusiasm through the re^rc^rship and into progrer^s. Vario'JS publications, listed
in the bibliography, ere beg'.nning to exert an influence. The Society of Professors
of Child Psychiatry has focusad some of its ireetings on rasearch. The diffi-
culties that counteract these positive tendencies are mainly those described by
Cohen and tlagel :
1. too much tenacity in holding to clinical beliefs unsupported by
research evidence,
2. too much dependence on the authority of highly respected sources,
3. too much appeal to intuitions or hunches as self-evident revelations,
4. too little use of reflective inquiry, independent of scientific bias,
and concerned only with the logical examination of relations between
objective data,
A third factor, cited by Jones, as a further "resistance" to rasearch is the
selection of residents for child psychiatry. He concluded that a process of self-
selection was involved in addition to traits considered desirable by training
establishments. Candidates impressed him as individuals who maximized subjective
and interpersonal elements, were tender-minded and humanitarian in their general
approach, and had needs to be assured that clinical and research procedures were
not mutually inseparable,
b) Attitudinal issues and sources of strain .
Psychiatry is poised upon a new era of professional izati on. While its stage
of development is lumped with the more highly developed clinical sciences for
policy purposes, psychiatry--and its underpinnings of knowledge — have received more
than a fair share of the current anti-intellectualism. The prevalent ahistorical
attitude provides no perspective on the advances of psychiatry from the era of the
all-purpose alienist to the increasingly differentiated coirmunity of general psychi-
atrists and subspecialists linked to a broad range of cognate disciplines.
General attacks on psychiatric research stem from a variety of concerns —
the self-imposed reactive separation of the researcher from his coirmunities of
ultimate reference — the patients and sanctioning bodies in the community. The
strains between researcher and the clinician, as well as the rapid rats of change
in service systems, is a source of discord and misunderstanding from within the
profession. The psychiatrist in a relatively novel service situation--e.g. , schools,
neighborhood centers, etc. — as well as the office practitioner, is too often iso-
lated from colleagues, colleagueship and knowledge systems that v/ould nourish
inquiry and its help to explain phenomena.
Other attacks are reactive to the intrinsic challenge to narcissism when data
imply a change in habitual activity or cherished belief. The urgency to solve
imirediate pressing social or personal problems when pitted against the mora delib-
erate process intrinsically required for authenticated knowledge, similarly
engenders frustration and misunderstanding. For any kind of disciplinary self-respect
the caricatured polarities between research and clinical service delivery can--
with any concerned effort and attention — be dissipated: the "noble researcher," (1)
bsseiged by barbarians, aloof, isolated in his elegant and pure concerns frcm the
clinician who is portrayed as all-knowing (at least to his clientele), but
unchallenged in his assertions, and complaining he is deserted in his front-line
50
dealings with "real" psychiatry. Beyond these intradisciplinary strains, we
face the general and often held belief that we know enough if we would only apply
it.
1) We know enough— we only need apply it . Such arguments ignore the funda-
mental notion that many applications would be unnecessary if we know more. Thus
the training of physiotherapists and rehabilitation workers about the management
of polio and its aftermaths is no longer required because of basic research and
its salient application to a vaccine. Studies of environment, diet and the like,
applied to the treatment of tuberculosis or of nursing procedure, or development
of anti-sera for pneumococcal pneumonia, similarly are no longer relevant.
But one should note that in internal medicine the very application of new
findings may take 5 to 10 years following a discovery for broadscale and sound
utili2ation--and with the added complication that new problems are expectably dis-
covered through the clinical experiences or applying a new therapeutic agent over
a period of time. Application— applied research--is in fact increasingly linked
to examination of processes, posing problems as well as evaluating solutions.
This should not be surprising since the very nature of science is that the solution
of the moment is often transcended by the question for the future. And appl i cation- -
if it is researched--often proves we did not know what we thought we did!
Frequently the politicians' or managers' demand for the application of what we
know is a cover for the lack of economic resources or the social will to implement
knowledge. Even if one were really to believe that the total of 80 million dollars
at NIMH labelled research were in fact in the support of authentic research (a
figure that might better be set at $40 to $60 million, about a third of which is
directed clearly to problems of mental illness), it is clear that this is not a
dent upon the monies spent by 50 states and the insufficient hundreds of millions
allocated for federal support of mental health services. In brief, neither divert-
ing the research funds nor requisitioning the energies and improbable therapeutic
talents of all researchers to serve in delivery systems v;ould impact the major
crises facing us in that area! The loss to the profession would be enormous.
None of these remarks obviate the pressing need for developing corrmunicative
mechanisms and skills to enhance utilization; or the research facility and method-
ology for testing out the field of application through predesigned and ongoing
evaluation, and monitoring of treatment systems.
Many of these complaints, then, bear upon the problem of the utilization and
consumption of research, or upon the general topic of how problems get posed for
research. The latter becomes more concrete in the power struggle for prioritizing
research or capturing its prestige for the sanction of other missions with no
serious research component.
2) The importance of knowing what we know . To all the issues of application
and utilization, or of targeted versus free research, or of basic versus applied
research (a futile problem--see below), two general principles are key: (1) to
know the state of knowledge and (2) to acknowledge values and objectives.
To know what we do know that we then wish to apply, we must examine how we
know it and then how well, and with v/hat certainty. This requires both a grasp of
methods and what they can and cannot do (be they "hard" or "soft") and a substantive
grasp of clinical phenomena. A perspective of the history of the development of
the knowledge at issue is also key.
51
In internal medical diseases there is a constant interplay following scientific
developments between old and new approaches and evaluation and debate on the rela-
tive emphasis given to one or another line of inquiry; surely the advent of the
pacemaker shifts the relative emphasis in certain dysrhythmias from pharmacology
to devices. In psychiatry this task of overview is difficult. It is not only that
there has been rapid development of different kinds of orders of information, but
also of the populations that are served and for whose welfare there is an authentic
need for attention. These populations range from infancy to senility, from the
culturally or economically deprived to minority groups, to problems of lower and
upper social classes, and all of these factors compete for attention as well as
mandate the currently required integrative task.
What is needed in basic and continuing professional education is: a general
understanding of the utility and applicability of different sources of information
and methods of knowing, of the relative roles of scholarship and of first-hand
experiences of phenomena. As one of the disciplines among the life sciences,
psychiatry presently has the pressing task of assessing and articulating the dif-
ferent current approaches (e.g., psychoanalytic, biological, behavioral and social).
It will require energy, debate and attention to assign their place and utility in
the understanding of behavior and for the treatment of a range of different dys-
functions.
For this kind of educating and educator, and for this necessary professional
activity, time, support and special focus are required. It is against this back-
ground of comprehension of what the "state of the art" may be that many issues of
priority, of targeted or so-called applied research can be better and more wisely
adjudicated.
3) Utilization of research and values and objectives . Application of what
we know requires a value orientation coupled with an identification of objectives.
For example, to apply knowledge to empirical systems— to service systems— requires
a judgment on what kind and quality of service we envisage. Judgment must be made
on what grounds — such as costs, values, or outcomes--we justify specific services
and demands to evaluate them.
Does the sponsorship of such service want evaluation of costs or benefits,
or both? More efficient and less costly distribution of patients to convenient
service systems may be wanted by an agency; this does not necessarily mean that
advances in differential diagnosis are also to be applied for the purposes of
identifying and treating with relatively specific means disorders to be found in
that system— such as manic-depressive psychosis. The suffering and personal losses
of mental disorder may be tolerated by a society in order to achieve the gain of
more efficient social services for a range of human miseries. But these values
and objectives are rarely stated explicitly enough to utilize what we know or to
sanction a breadth of inquiry that might go beyond the avowed purposes of the
system to be evaluated, discovering key overlooked factors.
Large scale social investments in psychiatric programs, as well as sanction-
ings of certain patterns of intervention, have over 150 years been based on the
notion that prevention is an obtainable objective, rather than assertions of the
need for a more humane approach to human dignity and suffering. From the era of
Dorothea Dix to the flourishing of mental hygiene and child guidance clinics in
the 1930's, there have been not only promises but practices that focused on a
wide range of dysfunctions, on momentary minor mal adaptations in children, for
example, with the aim of prevention and with insufficient identification or problems
52
and parameters such as diagnosis, character structure, coping styles, social
resources, genetics and family history and constellation, or follow-up--parameters
necessary to differentiate dysfunctions and interventions.
The research question must be precisely what it is that we aim to prevent.
We must then assess whether we have the knowledge to apply for effective preven-
tion of specified outcomes. For example, we still lack sufficiently differentiatino
data on the topic of crisis intervention. It is undertaken in a widespread clin-
ical belief that it can aid in adaptation over the short term and it can be justi-
fied on humane grounds and on clinical observation. It can call upon data from
the psychiatric experiences in several major wars. But we still cannot as yet
state whether and for how long, and for whom, long term outcome is affected.
The point is not the specifics of these examples, nor that any effort at
intervention should be vitiated. Rather such problems are cited to put some per-
spective on our efforts, to challenge assessment of our range of information and
techniques, in order that there could be a design of the inventory of techniques
that may be needed or that ought to be tested.
The point is also the value that we place on different specifiable goals.
The humane ethic of medicine indeed values short-term gains, and it also mandates
inquiry for prevention. What we need to know is where best to place our efforts.
We would like to know whether timely intervention in crises or enhanced attention
to perinatal care affect the incidence of the major psychoses or their ultimate
course. This would require finer grained studies than have as yet been mounted.
This would be an instance, then, where directions for research are apparent, and
allocations of effort are justifiable on professional ethics and the best judgment
of the current state of the art.
The posing of problems and their application, then, are not unrelated to the
sponsorship of research and the assessment of methods available, as well as objec-
tives. Recent administrative and budgetary allocations with respect to cancer
research are vivid examples of politicizing of the process of prioritization. They
demonstrate a breakdown of that community of peer review and critique which have
guided authentic scientific developments rather well. Neither the peer review or
political approach, of course, predicts the unexpected — but peer review is not
surprised by iti
Competition for top bureaucratic visibility and congressional attention has
now become a process antithetical to the sound development of professional knowledge.
Thus while advocating responsiveness to social needs that research can appropri-
ately supply, v;e also require some antidote toward the political or managerial
direction of research that could, if unchecked, foster a kind of Lysenkoism.
Aiding this trend is the all too frequent habit of researchers not carefully
guarding their inferences and general izations--the "summary and conclusions" of
their reports--and lending their work to mandate one or another social value or
preference. This has been apparent in certain studies of genetics and education
and in the areas of drug abuse and ecology, in which the toxicity of substances
is so conveyed as to influence prefered social values rather than advance knowledge.
We come once again to the issue of application and values in noting that out
of scientific data, judgment is required with respect to risks and gains and
53
objectives. The capacity to critique these judgments is a mark of professional
maturity, but so too is the acknowledgement that application and utilization of
findings requires the involvement and accountability of the consumer as well I
4) Basic versus applied science: Pseudoproblem . Fundamentally, it is not
the subject matter, or tne use of a particular methodology, or the necessity for
trial and error rather than elegant design, that characterizes the fundamental
utility of research— or, for that matter, clinical practice. Rather the key point
is the ability to see a point of leverage in the course of inquiry, to find the
exception to a "law," that can change the structure of knowledge about particular
phenomena and activities, and generate subsequent research directions or practices.
The ability to see in a "basic" finding (such as a deficit of dopamine in
the brains of Parkinsonian patients) an application (the administration of 1-dopa
in appropriate dosage) is the point. The finding that nuclear schizophrenia is
more closely linked to a biological mother with schizophrenia rather than to rear-
ing in foster homes might raise a question about rearing patterns and the incidence
of nuclear schizophrenia and call for a clarification of and specification of the
effects on development of rearing in orphanages or foster homes. Research in the
community for the prevalence of mental disorder may be motivated by the question
of the utilization of services by a mental health center, but can also identify
specific salient variables (such as anomie or alienation) as more accountable "for
utilization than perhaps symptomatology or social class.
The point is that, given a data base and a system of inquiry, knowledge can
be engendered that can be either used or ignored, innovatively applied to practical
systems--or to our notion of the way things happen. It is the issue of the pre-
pared mind.
It is also the issue of a community of inquirers who vary in talents,
interests and modes of approach and special knowledge, who may find in an animal
study or a clinical event the consequential finding that challenges knowledge or
practice. Nor does the immediacy o1^ the objectives distinguish basic or applied
research; it is perfectly clear that in so-called blue sky research there is far
more cogency and planning and criteria for outcome than business managers and
budget bureau officers are likely to appreciate. Nor is risk differentially
distributed between basic and applied research. There is high risk in both basic
and applied research, and there are low risk inquiries in both. Since research
activity cannot be sustained without the ongoing activity of inquiry, the guarantee
for ultimate or definitive payoffs is not always relevant. In fact, such payoff
is possible only at certain phases of a development of a problem. Small as well
as large steps and objectives are common to both basic and applied work.
It was previously indicated that in applying a research finding, contributions
to the basic structure of knowledge, as well as practical spin-offs, occur. This,
however, cannot happen if psychiatric researchers are not in touch with the cog-
nate disciplines— or if basic researchers are out of touch with clinical realities.
The clinician investigator who focuses upon a clinical dysfunction, rare or common,
can build a reference system, a structure of knowledge which may lead him far
from the clinic to inquire as to mechanisms, correlates or outcomes. Evolutionary
biology, neurobiology and the psychological and social sciences may provide the
model for a system for a comparative view on, for example, perceptual mechanisms.
This course of inquiry will enhance the clinician investigator's understanding of
clinical events and prepare him to find a point of leverage.
5k
That the results of clinical investigations of today are of interest to
neurobiologists as well as clinical psychiatrists emphasizes this view. Many of
the issues that give rise to invidious debate stem from the lack of critical mass
or development of the state of the art. It is especially difficult to assemble
within a single center a sufficient array of competencies to apply knowledge and
methods from basic disciplines as new questions arise.
While political, commercial or populist control of research objectives is
not to be fostered, sharp and worthwhile questions can be posed to science by
those in control of funding; they often— as do students--ask how problems of con-
cern occur and how well we direct our inquiries. Such questioning is healthy and
useful in many circumstances. That authentic new problems can be posed to the
scientific disciplines in this manner is also true. We return again to the commun-
ity of interests and interchange which underlie authentic scientific developments.
5) Multi -disciplinary research . The topics of multiple disciplines, multi-
disci pi inariTTesearcnT'aniproETinHcentered research pertain both to the organization
of a research environment, the relevant disciplines in it, as well as to a mode
of conducting research inquiry.
With respect to multi-disciplinary research, there is on the face of it a
simplistic logic which has long brought an unwarranted sense of virtue to managers
and bureaucrats who tend to advocate it. In fact, there is a documented history
of the banality and counterproductive stress and turmoil that ensues with multi-
disciplinary research when it is a collection of personnel from different disciplines,
supposedly working on a cormion problem. The collection has often been artificial
and forced, or under the domination of a charismatic leader. Multi-disciplinary
research as an automatic answer to disciplinary stubbornness in refusing to solve
obvious problems is inadequate.
Nevertheless, within the profession, perceptive critics and mavericks often
derogate disciplinary rigidities without necessarily subscribing to multi-disciplinary
research as the answer. These critiques, while salient and leading to new openings,
do not always emphasize the importance of and respect for the continuity of disci-
plinary knowledge and skills and the importance of the conservation and reassessment
of the useful past.
6) Multiple disciplines . An emphasis on bringing individuals of different
disciplines into a psychiatric research setting (or, less corrmonly, the obverse--
sending a psychiatrist into other departments) is often wrongly based on the notion
that if a problem is defined as, e.g., sociological, then the discipline of
sociology has the skill, knowledge and will to provide the answer. A careful
examination of cognate disciplines would indicate that this is not commonly the
case, or indeed the answers would be truly in hand. Generally the real problem has
been to capture the attention of people with special methods and background to see
if they would invent and apply their work in psychiatric research. When a highly
competent basic scientist does become interested in the problems of the clinical
disciplines, he can sometimes lead and teach with quite productive outcomes. This
has been apparent in the history of the NIMH Intramural Programs.
Nevertheless the simple placement of one or several Ph.D.'s from different
disciplines within a psychiatric research setting is in fact complex. It depends
on many subtle factors for its success. The topic needs further inquiry, and many
departments of psychiatry have had various histories of experience with it. For
the basic scientist, such a location can bring career identity, peer recognition
55
and security issues. Yet this is common for those who cross fields. Increasinaly,
the Ph.D. finds authentic collaboration, psychiatric colleagues who may be suffi-
ciently skilled in his methodologies either to comprehend their limits and uses
or to implement them, as v/ell as to deliver sufficient knowledge of his own to
make the collaboration "take".
These considerations bear on the linkage of psychiatry and its personnel to
both established and evolving new disciplines and to the way these are to be
articulated into the issues of research teaching and training, both in terms of
faculty and students who are involved. We have noted the fact that some traditional
barriers have begun fundamentally to change and that younger scientists have begun
to bridge disciplines and create significant knowledge in the pursuit of certain
problems. The receptivity of the environment to the strangers in its midst and
the preparation of that environment for them are probably key.
7) Disciplinary i'ocus . The timing and selection of the interdisciplinary
personnel or multiply-disciplined personnel often depends on what aspect of a prob-
lem should be approached and, on the basis of mature assessment of the state of
the art, of what best can be next developed. For example, 20 years ago the measure-
ment of hormones was conceptually absolutely important for biopsychological
questions. But it would have been and was difficult for a biochemically trained
investigator to move forward in applying such measures due to technical gaps. Today,
with the development of new knowledge (immunochemical techniques, e.g.), the appli-
cation of these measures to clinical dysfunction or to questions of psychological
state is an active area developed by psychiatrists with special training or neuro-
endocrinologists with special interests. The ability had already occurred within
psychiatry (by 1961) to apply and test rating scale techniques to capture clinical
observations for such correlative studies.
The arranging of mixes of basic and clinical sciences within one v/orking area,
is a trend that will continue. It should be noted that there is no intrinsic
reason that this not occur in a variety of settings under different auspices— be
they "brain research," "neural sciences centers," or "social problems research
centers," etc. But any such development would be in far better proportion if the
peculiar clinical accountability that runs through all of psychiatric training,
and which provides a special context in which the meaning and applicability of
research findings have some firm rootings and frames of reference, were recognized.
A focus on diseases, their diagnosis, mechanisms and therapy, is compelled by
clinical reality and, as we have previously reported, has been productive.
In brief, from a policy standpoint, it would be valuable for such interdisci-
plinary developments to occur in major psychiatric teaching, service and research
centers before fostering large numbers of such arrangements under other than psychi-
atric auspices. In general it has been true that findings from other disciplines
do not truly "take" until they have been filtered through the teachings of one or
several major psychiatrists.
No advanced clinical discipline worthy of respect can do without the exertion
of leadership for such arrangements in order to test out findings, give them
relevance and critique, as well as to formulate designs that may bear more cogently
on validity. There is a marked tendency precisely to avoid this arrangement on
the part of funding agencies and their advisors, and it represents a potential
schism in what could be a most productive development. Further, without such
development, professional psychiatrists are deliberately assigned as technicians
56
for service rather than participants in the growth and use of knowledge about
human behavior and medical problems.
VJe doubt that these issues differ for the other medical sciences and we are
aware of the power struggles and bureaucratic issues that occur between basic and
clinical sciences when such developments are fostered. In any event,, with a
critical mass of differentially trained people in psychiatry, and with suitable
arrangements, disciplinary issues can become less relevant as real knowledqe and
research findings evolve and prosper. Further, even cursory examination of
careers of M.D.'s show that people have begun, e.g., in clinical research, and may
well end up as basic researchers--and vice versa.
What should be examined in the agenda-setting process is the overall position
of the field of psychiatry and its resources with respect to development in other
areas. There 1s no National Institute of Mental Illness Research. There are but
few centers devoted explicitly to the major mental illnesses. There are, however,
techniques and templates for approaches to clinical states and this appears to us
to be a productive area for research and a time ripe for the extension of facilities.
The issue of proportion would argue that there should be some emphasis on this
research being implementable in psychiatric research and training centers. But we
would not argue for exclusivity once a balance had been established.
8) Probl em-centered focus . One-hundred-and-eighty degrees polar to this
important need for a significant center of research activity located within academic
psychiatry is the fact that mechanisms, processes and the nature of behavior may
well be discovered by not asking what appears to be a clinically relevant question.
For example, the role of neurotransmitters was explicated by beginning--not with
the question of affective disorders--but from problems posed from within neuro-
physiology and pharmacology. The sponsorship of psychiatry was important to this
development. Psychiatrically trained researchers with special basic science prepara-
tion had the readiness to investigate basic mechanisms and to apply findings from
the basic laboratory to behavioral and clinical phenomena. These facts were
crucial in both developing and applying this basic knowledge.
Exactly how a system of knowledge can be constructed from the starting point
of "a problem"— one that cuts across any clinical entity--depends on a variety of
factors. These include the cogency of the inquiry and the appropriateness of the
chosen topic to available methods. Thus focus on a general variable--such as
"change"— has generated the beginnings of a coherent body of knowledge relevant to
questions of clinical interest, but may be too broad a topic to lend itself to
deeply affecting the various social and behavioral sciences. The move in behavioral
science to understand the behavior of man in different social contexts, or the
institutions in which he operates, has relevance to the etiology, severity, course
and treatment of clinical dysfunction. The precise outcome is always a gamble,
but one, on the face of it, well worth further investigations to see what variables
can be further weighted and specified.
Frequently the psychiatrist undertaking research finds that the basic sciences
have not to his satisfaction built a body of knowledge about a problem area. He
may search for studies of CNS influences and mechanisms on asthma as part of his
psychosomatic research and be led to the study of brain mechanisms, his subjects
being guinea pigs. Later, a "field" is established as basic science personnel
extend a finding to articulate its meaning in terms of neuronal pathways. In study-
ing adolescents he may find the baseline data on normality inadequate and perhaps
57
find 20 years of work ahead with non- psychiatric subjects. The resistance to
this search among faculties or bureaucrats or legislators is an anti-intellectual
thrust against knowledge building that the profession should counter, by support
of the basic thrust of inquiry--of following a problem, begun perhans in the
clinic, through the courses and byways it may intrinsically require.
The point, in any event, is that specific problems, such as schizophrenia,
cannot necessarily be adjusted to specific methodologies characteristic of a
discipline. New methods may be required and may come from a variety of surprising
sources. They may or may not workl On such banal targets of inquiry as peas,
corn and bacteria, modern genetics and molecular biology have derived enormously
powerful tools for all the life sciences. Nor has the application of genetic
principles left the areas of ecology, economics and cultural anthropology untouched
(e.g., the study of different grains and their impact on social organization).
In general, then, as understanding develops of the principles and mechanisms
operating in development and through the various phases of the life cycle, as
knowledge about brain dysfunction and neurochemistry develops, as linguistics and
the communication sciences advance, we should anticipate some findings and methods
that will be applicable to everyday clinical operations and evaluations. But this
cannot be predicted with great confidence for any specific area--nor predicted with
some minimal confidence--without adequate scholarly assessment.
Problem-centered and targeted research often are initiated because of social
or bureaucratic urgencies. Impractical ly imposed questions will not in fact
assuage the agony of urgency. The recent history of concern with drug abuse offered
incentives and demands that specialists from specific disciplines apply their
knowledge and reassess it, as well as invent new approaches. But this drafting
of expertise from the cognate disciplines of psychiatry, pharmacology and sociology
proceeded without any support for the gaps left from the very disciplines whose
knowledge and experts were needed. Without sustained respect and support for the
cognate disciplines, there would be no coherent mode of approach to the next urgent
problem of behavior disorder that would compel the next "draft." Pseudodisciplines
often arise--as slogans--under such auspices, and rarely survive.
Often, then, problem-centered research should be clearly recognized as a
developmental problem requiring incentives and a careful arrangement of a critical
mass of specialists, or perhaps frankly recognized as a venture requiring trial
and error and assessment at a later time.
9) Health policy and health delivery research. The same problem lies ahead
for the development of health policy and service delivery expertise. It will
require the inducement of imaginative minds from management and systems theory,
economics and political science, as well as psychiatry, and some respect for the
sturdier disciplines and their development from which such venturesome talent is
recruited.
We have indicated the importance of evaluating the state of the art and for
the social sciences would note the survey conducted between 1967 and 1969 (by the
Committee on Public Policy of the National Academy of Sciences and the Problems
and Policy Committee of the Social Sciences Research Council). A series of state-
of-the-art assessments was published, encompassing subjects ranging from mathematics
to psychiatry (5). The issues of applied social research, of "social indicators
research," were hotly debated. Policy leaders in psychiatry should assess these
58
reports and their relevance to clinical problems and service delivery and health
policy issues. Such assessment should also include the practical issue that often
a competition for the same pot of funds for the development of social sciences
and of psychiatric research is a hidden agenda.
While recommending vigorous and responsible development of social research
in psychiatry and the psychiatric health delivery issues (including the knowledge
structure of Social Psychiatry, as well as assessment of the delivery systems of
Community Psychiatry), we would note that there is a paucity of predesigned, care-
fully worked through social research. One notable exception is a recent innovative
project on a negative income tax. Unfortunately the major funding agency exercised
little leadership in stimulating the kinds of research with actual service delivery
systems that many on the Commission feel require development. Such research is
difficult and it should be recognized that few societies have been able to design
social change with even a modulated trial and error, or "successive approximations"
approach.
But the need for policy research and further socio-cultural investigations is
an example of an area of deficit and one to be developed. One would predict cer-
tain problems could be readily tackled and others not. Fundamentally, the problem
is no different than it was in the '50's with biological research. It requires
sustained activity in the face of ignorance, trial and error, self-critique and
the evolving of a range of special skills and acquaintance with relevant knowledge
systems on the parts of various specialists that are involved. These tasks involve
the construction of a bridge from a foothold composed of partially assesses informa-
tion reaching to a more distant one as yet undiscerned.
10) Prioritization . Many of these issues have been implied in the previous
discussion^ The use of controlled incentives after assessment of the state of
the art by experts and the community of informed consumers can foster undeveloped
areas. Targeted research similarly requires some balance of judgment arrived at
after authentic assessment of the array of developments in the field. In practice,
contract and targeted research rarely call upon such peer review and information
gathering. Many opportunistic ventures in training and research can often be a
futile waste of monies because they were not designed as incentive and develop-
mental devices and did not borrow the sanction of the knowledge systems required
for a reasonable output, and did not plan beyond the initial phase of recruitment
for career reinforcements over time.
In any event, the prioritization of research is a delicate art-'intrinsically
it is informed risk-taking--and one in which substantive knowledge is too often
lacking during the decision-making period. If the trend toward contract research
being mounted and managed by those least acquainted with the substance of a prob-
lem, or the utility and limits of methodology is characteristic, there are also
some responsibilities of investigators in this process as well. They must locate
their findings and define their inferences carefully to guide the informed sponsor
and consumer whose interests motivate the research.
The psychology of research--its oscillation between extreme poles of venture-
someness and the restraint of perspective--and the uncertainty of reinforcement
lead to opportunism and search for the glory of the moment, as well as seizure of
the momentum of supporting agencies for sheer survival. Opportunistic use of
research findings can enhance the trends reinforcing pseudoresearch. This is
countered by the-ntrinsic exposure of findings to evidentiary review in the course
of evolving scientific activities.
In general, the attention of the young researcher is captured by the interest
of his mentor--which is why we would recommend several mentors within a research
59
environment. It is also captured by the immediate scientific subject that is
developing in his area, and it is generally natural that the investiqator will find
his greatest incentives for directing his efforts in the problem that he has
selected and the area of that problem that is most ripe for development.
This process, which taps both the intrinsic state of the art as a gyroscope
in decision-making, as well as fads and popularities within science, means that
many areas may lie undeveloped. Here department heads, as well as policy makers,
must make judgments about supporting new ventures and research, basic or applied--
that is less immediately popular, promising or attractive, but yet has reason for
being. We can recall that the enormous attention today on virology and imnunology
in cancer research was not so long ago a very rare concern, even in leading depart-
ments of pathology; yet some sense of the intrinsic importance of search kept a
few laboratories alive until the field was ripe for great thrusts.
We cannot adjudicate or describe how such judgments can best be made, and
for the purposes of this report would have to re-emphasize the issue of balance
and the importance to academic psychiatry of gathering its community of knowledge-
able personnel into a greater exchange so that values involved and the problems
posed can be more broadly shared, competently assessed and argued before decision
makers .
While we have noted a need for a policy of support that enables some central -
ity of emphasis and continuity on the issues of mental illness, clinical psychiatry
and its unsolved problems in service issues, we have stressed--and reiterate--that
this is a matter of balance, and further its implementation requires receptivity
to and respect for and lively interest in a range of different, often rapidly
developing basic science approaches that can immediately or in the future bear upon
psychiatric issues. The fact is that psychiatrists' research can and does unpre-
dictably contribute to the general knowledge of man, to specific developments in
related disciplines from physiology to political science, and work from other areas
may well be the key to psychiatric research questions. In scientific inquiry, it
could not be otherwise.
c) Definitions of research activities and researcher .
It has been suggested that the most comprehensive criterion to identify the
researcher is the pattern of sustained activities with investigative intent that
leads to a genuine and cotranunicable grasp of a topic area (1). In this view, the
recognition of specific competencies is emphasized. The facts are that there has
probably been more than necessary posturing about what is and is not research and
who is and is not a researcher than can be useful. It is true that in the other
clinical sciences such problems emerge, especially when bureaucratic and power
struggle issues between basic and clinical sciences occur. Such bureaucratic issues
affect psychiatry too. Granting agencies can stipulate overly sharp definitions
of their criteria of support of a teacher or of a researcher, or of faculty support
on a grant. Academic turf can be an issue, parallel to the problems in internal
medicine, when the clinically trained person undertakes methodologies or pursuit of
problems that might logically be the province of pharmacology, biochemistry,
psychology or sociology. Any undue stress on these issues, of course, eventually
affects the identification and development of the researcher caught between them.
While it is convenient to identify two poles: the highly trained investigator
in psychiatry and, far across the void, the practitioner consuming his reports--
we see in fact a much greater range of involvement in the area of knowledge generating,
60
sharing and assessment which we call research. A 1967 GAP Report ("The Recruitment
and Training of the Research Psychiatrist") identifies the research psychiatrist
as, "a medical scientist, trained in clinical psychiatry, who devoted a major part
of his energy to investigations bearing on the etiology, diagnosis, treatment, or
prevention of mental illness. He may work as a scholar with scientific literature,
be concerned with theory and methodology, depend mainly upon clinical observation,
or work in a laboratory; and he may use the techniques of any scientific discipline
to study human or infrahuman behavior." The Offers and Freedman (1) indicate that
the auspices under which research is conducted, the subject studied, the audience
to whom the research is communicated, are factors in identifying researchers in
psychiatry.
Unfortunately the choice of methodology often will determine the investigator's
acceptability as part of the community of concerned psychiatric workers, and that
this may also determine his relative status within the various subgroups of the
psychiatric community.
But if we anticipate a trend for the clinician to focus on special competen-
cies, we certainly will be developing a far greater number of informed collaborators
in research investigations. We already are aware of clinical psychiatrists who
participate in special investigations. He may be expected to have some special
role to play in collaborative research in investigations led by his psychiatric col-
leagues or other medical or social work, or psychology colleagues.
There are clinical investigators working in clinical psychiatry who oscillate
between the study of a patient population or the use of animal models, or some
basic science inquiry.
Some clinically trained investigators will be found totally absorbed in the
basic sciences, and it is our belief that they represent an asset because of their
original training and ability to return knowledge at some appropriate juncture to
a field in which they have been soundly trained and acquainted. Scholarship and
the life of ideas is a component of the knowledge-sharing, generating and assess-
ing activities and there are those whose theoretical or scholarly contributions,
or sharp clinical descriptions, are highly relevant to any discussion of research
and research training.
We would be opposed to polarizing "soft" and "hard" as definitions of research,
or researchers, but it is equally untenable to provoke the polarities of humanist
and reductionist or mechanist. It is the relevance and quality of communication
and evaluation of observations and inquiry, and appropriate use at the appropriate
time of specific methods in the course of advancing knowledge that is critical.
While we do not believe that treating a single patient is to be identified as
research, if ideas generated from a single case--or more frequently a series of
cases--are synthesized by the therapist and appropriately communicated, this can
instigate or influence and inform psychiatric research.
Since we are also aware that established mature investigators are engaged in
a range of activities around their research--teaching, administration, committee
work and the like— and that in many careers one sees a sustained trajectory while
others show intermittent occupation with research, service and scholarship--these
considerations simply reiterate the importance of standards, of community and of a
plurality of approaches. We believe this view is not just meliorative, but, in
fact, reflects inevitable actualities.
61
Communications about professional practices and new information occur in
many different forms: in informal colleges and colloquia of interested parties
and against a background of prevalent ideas and practices. These consist of
peer reviews; debates in societies; laboratory gossip; the preparation, publica-
tion and critique of articles; selections of accrediting boards and comnittees
for the review of issues and problems; and a variety of professional meetings
and symposia (1). All of these scholarly and knowledge-finding and knowledge-
assessing and sharing activities are supported by general social values which
respect a love of learning, the obligation to conserve, transmit, acquire and
assess knowledge of human behavior. The obligation is to draw upon these
resources in professional interventions. We must sponsor a high degree of capabil
ity for competence and special knowledge, but respect the interplay of theory,
hypothesis testing, and problem-posing from empirical experience. For any one
problem, it is very likely that the establishment of validity, relevance and
reliability will tap various competencies and frequently those of various
individuals (1).
Obviously an approach such as this must count on a high degree of substantive
knowledge and perspective on the part of policy-makers and leadership, and require
the provision of a range of resources at the phases of early development and
education and special reinforcements as both residency training and career lines
develop. That many disciplines tend to periods of over- focus and have periods
of diminished intraprofesssional integration of the states of their art is true;
the monitoring of this oscillating process is especially required for psychiatry.
d) Current financing of research and research training .
It is clear that the Congress and Federal govemment--unopposed by signifi-
cant popular sentiment — has currently targeted NIMH for reductions below previous
levels of research support. This has not been the case for other National
Institutes of Health. In Mental Health, expenditures for research have been held
almost level while inflation over the past four years has escalated. Funds for
new research starts may be well below $5,000,000. Recipients of NIMH Awards--
as those of all federal research awards--must devote more of the research dollar
to operating an overhead cost and less to pursuit of the question and the problem.
Intramural research expenditure has been held level and reduced by job freezes,
etc. Nor has research been a leading priority of the NIMH, since its major
efforts were directed toward service delivery.
The "health dollar" sees research and research training as a small component
of a large system— a management procedure that cannot cope with the intrinsic
developmental status of various fields of knowledge and inquiry. The Kennedy
legislation on research training required "pay-back" for a shorter term of research
training support than had been available, and does not enhance the institutional
capacity to train in research; it is discriminatory to the poor, whom it indentures
and is not designed for the realities of development required by psychiatric
research training as distinct from the developmental issues and problems in other
biomedical areas. Rather it is designed to squeeze prestigious medical centers
with any emphasis on research in order to extrude a service delivery product that--
along with requirements built into other pending manpower legislation— will be
geographically located in areas of need. The mechanisms for this social good,
then, strike directly at the educational and research capacities of institutions
rather than directly enhance service and utilization systems, and there is an
added bonus for the anti-intellectuals: an undermining of the knowledge generating
62
and sharing function of professional training and activity and its scientific
underpinnings! For final emphasis, this design for an experiment in coercion
has had little assessment of its probability in achieving the draft of physician
manpower it truly aims to achieve.
The support of NIMH for training of psychiatrists in research has had two
thrusts that have not had an exceptionally high priority; both have come under
some stress. One mechanism for research training in psychiatry were some small
Psychiatry Research Training grants to psychiatric training centers. They gen-
erally offered little support for equipment and research costs. Little over half
a million per year was allocated for such grants in 1973. On the other hand,
approximately 4-1/2 millions per year has been granted to a wide range of basic
science departments for biological sciences--occasionally touching upon the central
needs of psychiatric departments for research training; these generally were
departments of neuroanatomy, neurophysiology, neurochemistry, psychology, psycho-
biology and pharmacology, to support their predoctoral and postdoctoral trainees
in so-called "interdisciplinary" training, generally an interdisciplinary seminar
in the cognate disciplines or neurobiology. This fiscal policy states: Clinical
psychiatry is a service area and its scientific direction is a matter for others
to decide. Such policy further separates the clinical aspects of training in
psychiatry from its research base.
It should be recalled that studies from a few centers (e.g., Downstate and
Boston University) show an excellent product in terms of academic and research
impact of the support for residency research training. Such programs might begin
within the first or second year--generally the third year of training and extend
post- residency for one or two years, with stipend support supplemented by the
local institutions. The NIMH Biological Sciences Training Program was key in
several psychiatric centers for the development of psychiatrists in research,
although its major constituency was predoctoral and postdoctoral in a range of
basic sciences. The point is that no mechanism established laboratory space,
interdisciplinary faculty, equipment, and teaching costs for sufficient research
activity within academic training departments with the specific aim of enabling
individuals trained in work with the mentally ill to engage in and influence
research. A low priority of focus on academic psychiatry is the point. The issue
of proportion and balance, of which among the Federal agencies must primarily
worry about developments in brain sciences or child development or pharmacology—
and which about psychiatry— is no different than what universities face as the
balance of areas is adjudicated.
The other training mechanism has two prongs: the development of young psy-
chiatrists as investigators and the support of more mature investigators with
advanced faculty status. This is the Career Investigator Program (3) which later
became the Research Career Scientist Training Program, funded at approximately
$5,500,000 in 1973--3,720,000 of which ended up in medical schools and centers.
It most recently has, fortunately, been removed from the NIMH Training Division,
where it was exposed to 0MB (and Congressional) policy on training. Training
policy in research, in turn, has largely been shaped, both in the administration
and in Congress, by experience with similar programs in the other clinical med-
ical disciplines. The success of the program in psychiatry in retaining people
in academic and research positions--let alone sustaining investigators over 15
or 20 years of their work--has been astonishing.
A continuity of support—initial 5 years of training, followed by one or two
5 year periods for Research Scientists— was encompassed in the Career Program.
63
Begun in 1954, the data show only 3 M.D. scientists left to enter private prac-
tice. Of 68 M.D. 's completing 5 years of the award, 57 were, in 1973, still in
research, academics and public administration! The CORD program of the USPHS
data are not available; the success was, however, far less impressive, possibly
due to factors of selection or a different quality of sponsorship.
As of a 1973 review, this mechanism supported 124 Ph.D. and M.D. scientists
of various stages of development in 38 medical schools and centers. This has
formed a core of direct and explicit support for mental health sciences researchers
within academic institutions. While between 1966 and '73 it was serving a large
number of university departments of anthropology, sociology and psychology, with
recent cutbacks there was some inexorable prioritization of goals and objectives;
the fact that the vast majority of medical schools are dependent on clinical
income or funds based on student-teacher ratios and have no endowment for the
support of a mature scientist was taken into account.
Fellowship support (postdoctoral or special) has in the past been another
avenue for research training both of beginning and more advanced candidates.
Approximately 3.5 millions were used here—the major portions of which ended up
in mental health fields other than psychiatry.
Since research is learning by doing, a good deal of research training has
naturally come out of funds designated for research grants--supplying computer
or laboratory costs for trainees, if not some funding (for research assistants)
for those who want to undertake some research with a senior mentor. This hidden
tax on research for research training was perhaps sensible; today it is hardly
possible with research grant cuts.
Grants for support of behavioral sciences for medical student training may
have offered some schools some way of recouping costs for a part of a behavioral
scientist, as would the so-called undergraduate grants (of about $25,000 annually)
given in fiscal '73 to 103 medical schools for training of medical students in
psychiatry. (In fiscal '73: 3.9 millions for "undergratuate" training — i.e.,
students working for an H.D.— went to 103 medical schools; 1.65 millions for
"human behavior" training went to 59 schools--a total of 5.5 millions to medical
student education.) The fact that over 45,000 M.D. candidates in medical schools
receive mental health training and education in the principles of psychiatry and
that only 5% of NIMH training dollars were directly provided for this function,
further emphasizes the meager support not only for research and academic faculty,
but for the disciplinary knowledge which would influence all practitioners and
many allied professionals and paraprofessionals in medical centers.
Residency training grants have been the major source of support to reimburse
faculty and teaching costs not only for residents, but, de facto, for the nurses,
social workers, house staff, medical students in the teaching environment; for
some schools, stipends for residents have been critical because faculty have been
supported by service or state stipends, but the total enterprise represents an
investment of about 20% of the total NIMH training dollar in medical education.
Such grants cannot provide for the manpower required for the range of clin-
ical and scientific education that is expected in American medical schools and
clearly not for the research specialists on their faculties, let alone those that
might be developed. The availability of $600 "summer stipends" for medical
students attached to undergraduate training grants was an important mechanism in
64
the recruiting of talent into psychiatric research, whether that talent emerged
Into practice, academics or research as an ultimate career.
Private foundation support has been minimal and research for mental illness
has been far less attractive to donors than research in special areas: child
abuse; delinquency; drug abuse; school learning problems; geriatrics; brain
research. Some foundations prefer large prizes to be offered to a few eminent
researchers. One of the few small foundations explicitly directed toward psychi-
atry (the Foundations' Fund for Research in Psychiatry) has recently shifted its
policy only to the support of research training in clinical settings, and the
small Scottish Rite Fund has long given a focus to schizophrenia research and
research training. Some private hospitals (e.g.. Institute for Living, Menninger
Foundation, HcClean Hospital) have sustained research laboratories. The lack
of private endowment in most medical schools for psychiatry or psychiatric
research is astonishing, although the specific documenting of this fact is needed
for emphasis over this Incredulity.
There was an upsurge of state mental health departments Investing in research
In the 1950's and 1960's--largely to help attract clinical practitioners and
upgrade the overall quality of care, if not residency training. These and other
state support for research are now phasing out at an alarmingly Increasing rate
in most states.
The major investment in research— and hence a major site of research training-
has been the NIMH Intramural Programs, attracting top talent who serve their
military time as clinical research associates in clinical basic laboratories, or
occasionally in an NIMH extramural base. We must note, however, that few such
programs directly affect the environment in which the basic medical and psychiatric
education occurs. Nor was national policy on manpower ever aware of the need of
major teaching institutions to receive such associates on a nationally competitive
basis for service and training, during the 30 or so past years when physicians
were never exempt from the force of the draft.
The paucity of research space and equipment in the 105 medical school academic
departments of psychiatry that could be surveyed in 1973 has been documented by
Morris Lipton. Perhaps the Veterans Administration has been most durably and suc-
cinctly linked to academic centers through Deans' Committee hospitals since 1950,
but space and dollar expenditure data are not as yet available to the Commission.
The overall issue of regional ization and demonstration of optimal environ-
ments for the integration of research and clinical education is the issue. The
lack of any secure dollar candidly allocated for education and the relative
flabbiness of coherent policy giving central attention on psychiatric research
and support for implementation of training and research are, however, apparent.
This basic vulnerability — shared by all education and research— should be appre-
ciated if realistic means and goals are to be effected and proposed.
C: GENERAL GOALS OF EDUCATION OF PSYCHIATRIC RESIDENTS IN RESEARCH
The first general goal is to train psychiatrists to be professionals in the
scientific sense of the term— i.e., preparing them to prepare themselves for
obsolescence. This general aim comprehends within it the notion of how and when
65
a psychiatric resident can be a consumer of research, perhaps a participant if
not primarily an investigator. Some research findings should change his view
of the nature of things and some will directly affect his actual practices;
others affect how he interprets them, where he locates them in an order of certi-
tude. This habit of mind should not be taught simply in a research seminar.
The issue is how to integrate the attitude into the entire approach of teaching
fundamental skills in psychiatry. Clinical models and teachers are key. Perhaps
if it is remembered that the specialist in research is not at all necessarily the
brightest or most knowledgeable about general psychiatry, special knowledge would
not appear so arcane. It surely would be less so if clinical teaching utilized
research, and focused on special competence.
Pmong ancillary activities that enhance this approach — activities not
specifically labelled research—are:
1) The use of historical perspective on any issue involving diagnosis, a
form of treatment, etc. It is clear that the thrust of the therapeutic community
has occurred episodically throughout the history of psychiatry, perhaps emerging
most visibly in the birth of moral treatments. Different forms of treatment sys-
tems rely on reinforcing different motivations and behaviors; they require certain
attitudinal shifts with consequences of enhancing some treatment goals but not
others. The role of excitement with a new organizational change. Its effects on
accurate observations and on patient care, the forces that lead to stagnation and
to conflict, can all be discussed, the literature cited, etc. The point is that
no aspect of the clinical scene of training need be taken for granted. Any dis-
cussion of electric convulsive therapy for the treatment of a patient can include
some review of socio-cultural attitudes as determining the utilization of ECT, as
well as some serious review of the literature on risks, on memory and on methods,
on patient selection, response, etc. This is an aspect of clinical teaching in
which the use of journals that communicate scientific findings and opinion become
important.
Implementation : To aid this general approach in teaching of patient management
and issues of the selection of therapy, or mechanisms of therapeutic action, etc.,
state-of-the-art and review articles are generally lacking. Such review articles
that would discuss the way by which opinions and data are arrived at, the limits
such different approaches bring to Inferences that can be drawn, are Important.
Advanced students can, locally, be encouraged to such activity. If NIMH is to be
a source of some ongoing inhouse reviews or for general circulation (or preferably
to sponsor scholarship of this sort in the field), the highest of standards are
required. NIMH documents today do not carry with them the scientific force and vigor
that they once did in the late '50's and early '60's— simply because they are from
NIMH. These are, then, issues of teaching resources, of scientific communications,
to be utilized by teachers in the clinical setting.
2) The organization of many psychiatric services— perhaps more for econom-
ical reasons than for educational design— tend to make It appear that all patients
are pretty much alike, and all require pretty much the same response. Clinical
teaching can obviate this impression. Of course there is modern knowledge of the
subtypes of depressions; there are lively Issues of how affective disorder in the
presence of thought disorder is to be assessed and treated; the diagnosis of
delirium has EEG and behavioral-observational correlates, etc. An emphasis on
problems of differential diagnosis on the one hand, and diagnosis of personal and
social assets and liabilities for the purposes of treatment on the other, can be
taught. The availability of new psychotherapeutic drugs, of the relative advantages
of one or another form of supportive therapies, and the data at hand to warrant
66
one or another opiniQn--these focused activities in clinical training will be
difficult to convey if the actual service delivery does not practice this. It
is one thing to indicate how pragmatic solutions must be arrived at for economic
reasons, for purposes of doing rare for many than less for a few, but this should
not obscure a learning experience in which there is a striving for a special
intensive view of the individual patient and the search for the therapy nx)st
specific for him.
In psychiatric wards, the subspecialist is usually not a part of the routine
consultation and teaching about the expected range of problems, let alone diffi-
cult problems. This is markedly different from teaching, even on a general medical
ward. If clinical work entails a problem orientation in which objectives can be
stated, this would help. In any event, an atmosphere conducive to an appreciation
of research--or perhaps, rr,or8 felicitously, of evaluated knowledge on behalf of
the problem patient at hand— is required. Teachers can help the student with the
paradoxical fact that confidence as to how to proceed with the therapeutic rr^asures
at hand is important in patient management, and at the same time modesty as to the
enduring verity that lies behind the treatment approach chosen is necessary. Such
teaching sets an academic tone and a receptivity to research.
Implementation : This requires some attention to faculty and their continuing
education and accessibility to seminars and colloquia on a regional or national
basis which helps the teacher to enhance his knowledge. It requires faculty
resolve in clinical teaching. If the core academic faculty have these teaching
goals in mind, then it is quite possible to help the student pragmatically to
adjust and historically and scientifically to understand the nature of certain
service systems where such differentiated inquiry may not be able to be practiced.
The distinction between the logical status of a proposition, the scientific evi-
dence bearing on it, and the clinical task of understanding the meaning of behavior--
which is different than the cause— can be taught in clinical conferences. It
should be the aim not to make the patient the victim of the limitations of one or
another generalist or specialist on the faculty. The way the faculty practices
referral and consultation when special skills are needed will be important as a
modal for the student as he learns to assess his own limits and the skills his
patient requires and can realistically utilize.
3) Acquaintance with substantive knowledge in the social and behavioral sci-
ences, in the evolving literature on diagnosis and etiology, and the discovery of
new physiological mechanisms or identification of side effects, will help to enhance
the research attitude. The sciences that study development are particularly impor-
tant for clarification of developmental physiopathology.
Implementation: Journal clubs and special seminars demonstrate a special focus
on research that should be in ewsry residency program. Seminars that have the back-
ing of the total faculty that are focused upon the state of the art of theory and
practice also are part of the environment in which psychiatric residents and medical
students should be taught.
4) Residents should be exposed to research problems by living with people who
are doing research. This is particularly important for child psychiatry.
Inplem.entation : The organization of departments of psychiatry should be
arranged so that clinicians and investigators mingle as much as possible. Tiiis has
implications for planning of space, for curriculum planning, and for the organiza-
tion of staff activities.
5) The question arises as to specific core curriculum in research methodology,
the history and philosophy of science, and some of the special issues involved in
dealing with subjective events. Some model curricula need construction and debate
and testing. None are known to us to be flawless.
67
The logical analysis that is possible in dealing v/ith complex behavior or
subjective events should be taught along with experimental design, and some of
the assumptions behind the statistics the consumer is likely to encounter. The
liveliness and history of ideas actuating different theories and approaches
should be conveyed.
Implementation : The Cormiission was aware of a variety of attempts to hold
special research seminars or seminars in methodology. These have often been
failures, or successes only for brief periods of time (while the faculty and
students were excited about a new development), and remain a challenge both for
faculty and students. The challenge is to develop a kind of relevance in which
these methodologies, issues of statistics, experimental design, can be taught
in an interesting manner. No one method is known to be reliably successful.
It is also to be remembered that many students today enter residency with
a far better preparation in biostatistics than was true a generation ago, and
some of these seminars may not be useful to each student. Peer learning is use-
ful here, and a selection of some residents with special backgrounds can enhance
such teaching.
6) Whether or not the psychiatric resident should be required to partic-
ipate in or execute a research project or scholarly paper is an issue. In favor
of this is the truth that involvement teaches. Against this is the experience
that this is often a bitter pill, hardly touches the student at his particular
point of anxiety and interest in the process of learning to become a psychiatrist;
is seen as a foreign body — and subtly reinforced as such fay a nun*er of the
faculty.
Some training systems, such as those in England, require a dissertation for
graduation or special certification. It is possible a general lack of emphasis
on clinical investigations— on the observational approach in which classification
and counting of some obvious variables has been discouraged (as if these were
not relevant to clinical work)— might mitigate against the involvement of every
student in research or in a research paper. The 1967 GAP Report did review some
of these issues (4), as did Psychiatry as a Behavioral Science (5).
7) The fact that there are limitations in research personnel — that they
are not evenly distributed (even across 108 or so nodical schools) with residency
training programs — creates a problem for the involvement of the resident in
research. Whether or not residents should be taught some of the current observa-
tional techniques, the use of rating scales on their clinical services, or through
a special project in order to grasp how events look when one is involved clin-
ically, or when one begins to ask questions about them from a research standpoint,
are topics for discussion.
Implementation : Manpower and research resources are at issue here, as
well as determination as what is the best method to accomplish the end of an
informed consumer and participant in the evolving body of practices and growing
body of knowledge that is relevant to them. The use of guest lecturers,
institutional GRS funds to involve cognate disciplinary experts, and—again —
a requirement for scholarly or Investigative output prior to final certification,
are possible mechanisms.
68
D.: DEVELOPMENT OF RESEARCH SPECIALISTS
1) One of the Issues in all residency training is to recognize talent
where it may be and research talent where it may occur, and to allow it to con-
tinue to develop. Individuals are now coming into rredical schools and into
specialty training with a variety of different backgrounds, some quite highly
developed in the behavioral or biological sciences. Their recruitment is a
special topic. In general, special research interest appears to be manifest
early in the education of the college or medical student career.
Residency programs should be sufficiently flexible to accommodate some of
these individuals and without vitiating the requirement for special expertise
in the core skills and arts of diagnosis, patient care and the application of
individual, group, psychotherapeutic or conditioning therapies, permit the curi-
ous to have more special experiences. Such programs should be equipped to aim
this talent toward post- residency development.
Implementation ; This will rest not only on the design and flexibility of
the core residency program, but on the resources for support of education and
the necessity of residents for services. The issue of specialized regional
centers and faculty and their availability to all training centers also is
raised. Visiting fellowships for promising residents can be useful. Access-
ibility of centers with minimal resources to specially skilled persons and
centers to aid in assessing and sponsoring talent is key. Facilities and funds
for involving students in actual research are required,
2) Pathways to a career focused on research in psychiatry must be kept open
and several different phases in the development of these personnel can be
envisaged. Jobs must be ready for the developing academicl It is doubtful that
we need more than 5 or 10% of graduates moving into a specialty in academic med-
icine and research.
Not all who start must end up as stars. It is an article of faith that a
better teacher emerges if he has had some research experience and nothing is
to be lost in the trajectory of some academic careers if there is at least some
time spent by faculty in research while other areas for focus may later be
chosen for special attention as time evolves.
Some complicated areas of research do require time— as Kubie has often
emphasized — for maturation and the ability to utilize the frames of reference
that are relevant, as well as a chance truly to observe behavior change over
time. There are always a few candidates for research careers who discover
their methodological emphasis was more of a defence than an asset and shift
emphasis, while others lose their phobia about looking or reporting. These
variations on a career theme can be readily accoirmodated by academic environments
that value quality in its various manifestations.
Implementation : Both facilities and support, and most critical an environ-
ment reinforcing these developments, are necessary. The devices of psychiatric
research training grants and for associated teaching costs and stipends have
some advantage. Reports from the Boston University and Downstate groups show an
excellent product of such training begun during residency and extending a year
69
or so beyond it. The individual fellowship has an advantage. One would opt for
multiple tracks and support mechanisms because these may fit different institu-
tions and different individuals at different phases of their career needs.
3) If clinical expertise in special areas--alcoholism, the depressive
psychoses and dysfunctions, family and group therapies, sexual dysfunctions,
phobias, etc. — are encouraged, then these subspecialists are likely to need some
form of special research training, and perhaps engender some candidates for full-
time research career development. V/e consider this clinical expertise a prime
source of future clinical investigations and investigators.
Implementation : Subspecialization also can be enhanced by the organization
of service and data bases within clinical sites. The question of whether or not
there should be regionalized centers with the obligation to provide special train-
ing to young people will have to be discussed and analyzed. The necessity of stu-
dents to leave their home base and move elsewhere often robs the parent institution
of feedback of trained talent, and this represents a serious problem. "G.R.S."
support— institutional grants to reinforce the clinical subspecialist with working
funds— may be key. Recognition that clinical investigators usually must organize
their populations and services and oversee them is critical; NIMH supporting
mechanisms fail to visualize the model we describe, and discourage the administrative
tasks necessary to manage clinical research. The use of seminars for a group of
trainees, special courses in computer technology, etc., needs no comment. Lively
discussion among learners and experts is key.
4) Since a major part of research training is learning by doing, it is
obvious that research sponsors and facilities are required.
Implementation : The lack of minimal facilities in almost every educational
institution in which animal, behavioral or biochemical investigations can be
conveniently carried out, in which access to computer programs that would enhance
clinical investigations is difficult, etc., presents a real and agonizing problem.
The research career scientist program is of key importance, both to locating
faculty within a wider range of medical schools and training centers and to pro-
vide ladders through which individuals can develop a special expertise. It must,
as noted, be expanded to support clinical scholars. Research project support for
bed costs or nursing aid is absolutely crucial for clinical investigations to be
enhanced.
We also recomnend General Mental Health Sciences support grants for either
faculty or trainees or facilities, along with clinical scholars grants to bring
ideas into focus for programs or knowledge.
5) The option of charging specialized centers with the obligation of sharing
their faculty with a number of teaching institutions and of opening their labor-
atories to a number of trainees is not without its problems.
Implementation : First of all, the most meaningful training occurs where clin-
ical and research operations occur as part of the atmosphere and in the same
setting, and in which departmental leadership shows that "it means it". The sharing
of faculty can diminish the expertise and environment of the specialized research
center. Obviously, the quid pro quos, in terms of financing, v/ould have to be
well worked out. The fact earlier alluded to--the thin line of special expertise
7Q
presently available in academic psychiatry— means that we must not threaten the
centers or individuals with constant absence from their laboratories and research,
Nevertheless, the opportunity to send students to special centers for
periods of time, to be determined by their sponsors and teachers, is important.
It would be entirely unacceptable--especiany in view of recent directions in
some ADAMHA career teacher programs— for administrators inexperienced in devel-
oping academic and research talent to specify curricula and some required period
of time. The forgotten fact is that competitive grants for development of
teachers or researchers— if one is a winner--are enormously reinforcing and have
been notably successful in adding to the manpower pool. Peer review and critique
prior to judgment and award of the grant are sufficient to pick a pool whose
development is likely to be beneficial to academic growth. Punishing developing
investigators who may teach— and teachers who may research— is a foolish policy.
Assessing the adequacy of local sponsorship for a good outcome; the elective
option to travel to special resources; group conferences to reinforce esprit
are sufficient federally designed rewarding mechanisms to foster development.
Local reinforcement--"meaning it"— in terms of rewards for the developing
researcher and academic are, of course, indispensible. The young investigator
who wishes to gain authentic knowledge in the basic science which he is using to
apply to a clinical problem, for example, should have the opportunity to be sent
for whatever period of training and apprenticeship that is required and to try
his wings locally as well as nationally.
6) The training of specialists in research can often be enhanced by a mix-
ture of trainees who are on problem-centered issues. It is advisable that more
than one approach to a problem--be it a clinical problem or a way of understand-
ing brain function--be available, and that the student have a chance to choose
among mentors.
For all special (as for residents generally) trainees, it is often useful
for people of different backgrounds to be in a training group together. Basic
scientists have become increasingly comfortable with the young M.D. with a
"liberal arts" in human biology, but often with special skill. Jealousies are
overcome with experience and a peer group of different disciplines adds vigour
as well as preparing future scientists to cross disciplines. The ability to
mount these environments will vary widely from institution to institution.
Obviously the greatest power lies where a medical school is in close proximity
with its university and with its basic biological and social sciences. While it
is often analagously argued that a free-standing medical school can bring spe-
cial focus to training of practitioners, it is an issue of focus versus intellec-
tual and scientific power. Finally, what is required is a ladder of support for
those willing to climb it, a respect for the acquisition of depth in the field
in which expertise is acquired by the M.D. on behalf of his research.
7) Researchers who are more developed may have needs for special re-tooling
and there should be support mechanisms for this. Special fellowships are key.
E.: IMPLEMENTING MECHANISMS FOR THE SUPPORT OF RESEARCH TRAINING
Many of these have been cited throughout this report (see Bb, Be, Bd and D).
Certain principles become apparent--the noted vulnerability of any device for
direct support for education, the vagaries that attend any allocation directly
71
for research activities, and the general devaluing of research training, let
alone research education, as a luxury. Even within the mental health area the
allocation of funds for these activities are small in proportion to inadequate
funds for more socially pressing priorities, and the financial gain in closing
out these funds are hardly impressive budget-cutting devices --or aids to social
priorities! We have already noted, in any event, that support— from within the
profession for research and the development of researchers--is often flaccid
(few prizes, scholarships, etc., come from professionals training candidates in
psychoanalysis or from other private practice or professional or lay groups);
NAf^, A. P. A. and A.M. A. have not been notably forceful advocates for the maintenance
of stable academic growth. This in part is because of larger agendas of such
groups, and in part the relative isolation of researchers from decision-making
and ineptitude in serving the needs of consumer groups for knowledge.
If one were to reconmend nechanisms without some notion of the overall
national priority given to research, several different options (for awful times,
hard times, reasonable or good times) would have to be examined. Certain gen-
eral mechanisms and policies appear, however, to be relevant.
Either for purposes of acconmodating to the economy of scarcity or for the
purposes of development, regionally distributed centers of special focus in
research that are receptive to the region's needs for research training and trainees
are probably an important mechanism to consider (see D). It might be worth think-
ing of reimbursements to less developed centers for sending faculty or students
to such centers in order not to weaken academic developments and incentives in
less equipped facilities. The principle is to consider the impact of any such
centers; they should not lure manpower or funds that weaken clinical training
institutions for whom research developments are not as yet timely. Reciprocally,
any reinforcement of regional centers should not disengage them from their own
link to the general life science disciplines and research and service and educa-
tional activities that place psychiatry as a part of the life sciences.
In turn, the equivalent of "general research support" and support for man-
power for the training of all medical students should be a priority expenditure
of training funds that impact all medical education. High priority for funding to
permit the hiring of special faculty for "undergraduate"— pre-M.D. --training
needs is recommended. Numerous incentives can be thought of. GRS funds for
exploratory research (for selectively reinforcing local research activities )
would impact on education and clinical training sites would be important. Clinical
scholars grants for 3-5 years, and Mental Health Sciences Research Support for
personnel, equipment or pilot funds are a possibility (see D),
Similarly enhanced support for distributing knowledge, development of cur-
ricular materials, state of the art resumes, support of journals and colloquia
and special continuing education mechanisms, require attention. Mechanisms are
needed within sites not strong in research to enhance the collaboration of basic
sciences within such institutions should be devised; funds in the hands of
departments of psychiatry trying to develop a research atmosphere can provide
pov/erful local incentives (as in fact the early training grants did) to keeping
psychiatry a vigorous force within the local academic medical comnunity.
The acquisition of in depth knowledge is a continuing need of trainees
and post- residency personnel. The offering of sabbaticals and of special train-
ing throughout the center of academic research and clinical workers, requires a
72
support mechanism. The development of Special Fellowships and enhancement of
responsivity to specific needs for faculty development throughout the country
require investigation so that rules and regulations and terms of support are
responsive to authentic needs.
The M.D.-Ph.D. programs in other clinical sciences have been useful devices
by which the attention of the very young is early captured and expertise devel-
oped. Sponsorship of some of these in psychiatry, in which behavioral science or
biological science degrees do not divorce the student from his interest in psychi-
atric problems, laboratories- and issues, is a mechanism to be explored.
Interdisciplinary programs while perhaps out of proportion with respect to
other mechanisms that would foster psychiatric research (see Bd) are nevertheless
excellent mechanisms for enhancing the dissemination of knowledge and the genera-
tion of interest and expertise among disciplines seeking to enhance careers in
research.
Flexibility of support for research training within the psychiatric residency,
minimal equipment and pilot research funds should be a part of any psychiatric
education funding. The principle we would advance— one that has hardly been
"sold" to policy -makers— is that the arrangements for a sound education and sci-
entific understanding of professional activity comes firstl Whatever the size of
such activity, whatever the dollar support, this is the floor, and special pro-
grams responsive to special and perhaps transient but urgent social needs, must
be built upon that floor, not by destroying the floor.
Minority recruitment, as well as recruitment of youth, is a key concern.
Special incentives will be necessary since research is still a less financially
remunerative than service, and is a high-risk career. On the other hand, enrich-
ment of the field, especially in social and cultural research, the sharp identi-
fication of relevant issues and posing of meaningful problems, can be enhanced
if attention is given to mechanisms for research careers for minorities. The
structure of knowledge can also be enhanced thereby. Midcareer support for
special training might--at this moment— be propitious as well as recruitment of
the young.
It should also be recognized that much field research and clinical research
involves the information and participation which a range of variably and vari-
ously skilled workers can and do bring to a project. Support for research careers
in the allied professions— nursing, mental health aides— would only reflect
reality: that these are key observers and participants in clinical research
whose knowledge helps sharpen the validity and relevance of findings and the ini-
tial design of research for that goal.
Needed both for knowledge and as a mechanism for enhancing research activ-
ities and in recruiting other disciplines ^O- psychiatric, problems, are facilities
for a data base for clinical populations. Were these more soundly supported,
with continuity of support, then the observational impulse could be given some real
basis. The design of follow-up studies, of longitudinal studies, studies of the
course and natural history of disorders and of their regulation and consequence
in different social contexts, becomes possible. Any clinical operation, then,
has the opportunity--with a data base--to attract researchers. The question of
sites of research critically bears upon this. Such case registers and data bases
if linked to an adequate professional environment--or if there is access to it
73
by researchers--can both foster deficit areas in the social science aspect of
psychiatric researchim? the attractiveness of a variety of sites--with the
bonus of a capacity to involve on-site trainees and medical students in projects
utilizing the base. Many research problems cannot--and should not— be centered
in the home base of the university or medical school training center, and the
field would be poorer if other sites v/ere not rich in reserach activities.
Finally, we come to two major implementing mechanisms and principles. One
is that multiple means of support are required. This is not only suggested with
the notion of human fallibility in mind. In view of the varied arrangements
in American medical education, let alone service delivery systems, the proposed
armamentarium (of institutional support, special fellowships, data based field
laboratories, career scientist awards, clinical scholars awards, basic research
equipment and curricular supplies within general education grants, interdisciplinary
programs, special incentive support for interdisciplinary education run by
psychiatry departments, M.D.-Ph.D. programs, etc.) as an array, is most likely
to be selectively responsive to the range of needs. The survey of the degree
of federal dependency of American medical school psychiatry departments indicated,
for example, that state supported schools receive about 25% of their faculty and
residency support from state and local government, whereas private schools receive
only about 10" from state resources. On the other hand, large federal health
programs such as CHHC and the V.A. provide significant support — but only for about
20% of medical departments of psychiatry, in the case of the CMHC's, and only
33% of the medical schools in the case of V.A. support.
The second principle and implementing mechanism focuses on whether or not
there will or will not be general support for the fundamental education out of
which all the special competing needs of society can then draw. A statute already
requires approximately a 1% "tax" on HEW health programs for "evaluation." It
is dubious that these funds are well deployed if one looks at the total state of
the nation's disarticulated education, service and research programs. Nevertheless
a "tax" mechanism would be an important way of highlighting the linkage of the
systems to which we have referred to throughout this report. It would remind both
bureaucrats and legislators of it. Thus a "tax" should be levied on every health
service dollar, which then would enter a pool to support research and education
programs.
It is difficult to convey the ambivalent awe and unthinking arrogance with
which the products of basic education and the very visible (hence vulnerable)
institutions associated with them are approached by consumers (including critics)
for the talent, direction and leadership and personnel and the authenticity they
know are there. But it is, in fact, a "system" looping from legislators and con-
sumer to knowledge sharing and generating institutions. The financial symbol of
this would be such a tax.
The principles of the governance of the research and research training enter-
prise should not be directly linked to the health dollar tax. Host health facilities
are not the primary responsibility of the researcher and the research process is
not well governed by government, populist, or corporate control. Rather it is the
interplay and appropriate distribution of accountabilities and responsibilities
that is required to repair our current disarray. Coupled with this is the necessity
for communication among the involved parties which can produce a sound base for
enhancing and disseminating the advances we have in hand and those we can antic-
ipate with some confidence for the future.
Ih
BIBLIOGRAPHY
1. Offer, D. , Freedman, D.X. & Offer, J. "The Psychiatrist as Researcher,"
in: Modern Psychiatry and Clinical Research (Eds.: Offer, D. & Freedman,
D,X.)T Basic Books, New York, 1972.
2. Arnhoff, F.N. & Kumbar, A.H. The Nation's Psychiatrists - 1970 Survey .
Washington, D.C.: American Psychiatric Association, 1973.
3. Boothe, B.E., Rosenfeld, A.H. & Walker, E.L, Toward a Science of Psychiatry.
Monterrey, Calif.: Brooks/Cole Publishing Company, 1974,
4. The Recruitment and Training of the Research Psychiatrist , Volume VI,
Report No. 65. New York, N.Y, : Group for tne Advancement of Psychiatry,
1967.
5. Psychiatry as a Behavioral Science (Ed., Hamburg, D,). Behavioral and
Social Sciences Survey, Prentice-Hall, Inc., Englewood Cliffs, N.J., 1970.
6. Freedman, D.X. AACDP Survey of Federal Support to Medical School Psychiatry.
Testimony to Senate Subcommittee on Labor and HEW, July 25, 1973.
( Archives Gen. Psychiatry , in press, 1975.)
7. Anthony, E.J. "Research as an Academic Function of Child Psychiatry,"
Archives of General Psychiatry , Oct, 1969, Vol. 21, pp, 385-391.
8. Anthony, E.J. "The State of the Art and Science in Child Psychiatry,"
Archives of General Psychiatry , 1973, Vol, 29, p. 299.
9. Anthony, E, James. Explorations in Child Psychiatry . Plenum Publishing Co.
10. "The Making of a Discipline," in ftodern Perspectives in Child Psychiatry
(Ed., Howells, John G.). Springfield, 111.: C.C. Thomas Publishers, 1965.
11. Jones, H.G. "Research Methodology and Child Psychiatry," in Modern Perspectives
in Child Psychiatry (Ed., Howells, John G.). Springfield, 111,: C.C. Thomas,
T965:
75
BEHAVIORAL - SOCIAL POPULATION RESEARCH
Suggestions for Needed Research and Recoraiiendations
to the President's Biomedical Research Panel
Submitted by:
Vaida D. Thompson, Ph.D.
President
Division of Population Psychology
American Psychological Association
Director, Academic Programs Office
Carolina Population Center
University of Ilorth Carolina
Chapel Hill, i'orth Carolina
Introduction
On behalf of the Division of Population Psychology of the American Psycholo-
gical Association (APA), I wish, as Divisional President, to express appreciation
for your invitation to present our views* on behavioral population research to
the President's Biomedical Research Panel.
Recognizing the importance of this as an area of growing social concern, the
President of the American Psychological Association created, in October 1969, a
Task Force on Psychology, Family Planning and Population Policy. The final
report of the Task Force is appended to this statement. Subsequently, concerned
psychologists formed an APA Division on Population Psychology whose views we are
representing.
Psychologists are concerned with the study of behavior. We believe that the
many aspects of population, fror; fertility regulation to migration, may be
conceived as examples of human behavior occurring within the context cf a
*These views do not necessarily represent policies of the American Psychological
Association.
77
particular socioeconomic and environmental context and thus, appropriate for
population research. V/e are dedicated to the view that population is an inter-
disciplinairy field, requiring cooperation and understanding anong the range of
behavioral and hioinedical sciences if progress is to he made in understanding
the dynamics of population behavior, utilize more effectively already available
infonaation, and fill the existing gaps in knowledge.
We shall try to address ourselves in the oral presentation to the need for
behavioral science research in the field of population, and will present recon-
mandations for consideration by the panel. A ir.ore extensive statement is
appended.
The following issues will be focused upon: l) the current status of popu-
lation growth and the importance of population processes as researched targets;
2) basic assumptions concerning the complementarity of behavioral-social and
bio medical sciences in population research; 3) the nature of contributions
to be made by behavioral-social sciences, particularly by psychologists; U)
population issues which require further attention, with particular attention
on those which require intensive multi-disciplinary study; and 5) recommendations
concerning funding, cross-disciplinary communications and dissemination of
findings to the public, and training.
I . The Importance of Population Processes as Research Foci.
Many government officials and members of the scientific community may have
been lulled by both scientific and pop-xLar reports of decreasing fertility into
believing that population is no longer a high priority target of research. Current
fertility rates are not necessarily predictive of future fertility of individuals
78
or cohorts. We do not fully vmderstand the reasons for current fertility
decrements, and thus cannot know whether current trends will be maintained.
Today's college students, for example, express intentions to have two children.
They give as their reasons economic restrictions produced by greater fertility.
However, in research interviews, they continue to prefer large families; they
also suggest that they will have more children if their ovm economic situation
is better than anticipated and/or, if low birth rates prevail. Such thinking,
if widely shared, could portend up-swings rather than continued low levels in
fertility.
Also, there remain population subgroups with ever-increasing unwanted fertility,
For example, unmarried teen-age pregnancy has shown a marked increase over the
past decade from 259,000 to i*07,000, a 50'^ rate increase among females under age
20. Concomitantly, contraceptive usage in these groups remains poor: 195 of those
reporting intercourse report that they "always" use contraception; 62.9^ report
"sometimes"; and 15.75 report "never" (Kantner and Zelnik, 1973). It should be
noted that, while family size desires are a focus of study for social psychologists,
the complex of problems associated with unwanted fertility require the attention
of scientists in both behavioral-social and biomedical sciences.
Even if uncertainties about future fertility are not so great as to portend
drastic future population growth and if unwanted fertility can be reduced with
less than maximum effort, there remain at least two reasons why population research
must retain a high priority.
First, the population field does not simply encompass growth and over-
population problems but also includes study of stationary and declining populations.
Such populations present many problems, e.g.: the declining labor force; in-
79
creasing numbers of older persons, with their unique psychological, medical,
and service needs, declining needs for the products and services of the econony,
and population redistribution, ^v'hatever the population trend, the phenomena and
processes involved are poorly understood and thus require continued — in some
cases, increased — research effort.
A second concern which underscores the need for population research is
population policy. Informed policy making, whether concerned with transportation,
housing, industry, taxation, medical care or other matters, requires greater
attention to population processes and change. If our governiaent is to develop
appropriate national policies or to provide informed substantive input into inter-
national planning, it must receive guidance fron research directed at an under-
standing of the multiple and complex problems assoc" '=*°'^ with population growth,
change, and decline; population distribution and migration; and issues pertaining
to fertility and mortality, including maternal and child health.
II. The ?'eed for Behavioral -Social, as irell as Biomedical Ponulation Research_.
During F.Y. 197'*, federal support for population research in the biomedical
sciences was approximately tliree times that for the behavioral-social sciences.
The largest proportion of research in the former was in the area of reproductive
processes followed, to a lesser degree, by contraceptive development and contra-
ceptive evaluation.
We applaud the accomplishments of biomedical and behavioral-social populatior
research, and express gratitude for governmental support. In our opinion, it is
important to draw the attention of the Biomedical Research Panel to those
behavioral-science contributions which cannot be made by the biomedical sciences.
80
but which those disciplines need if their ovn contributions are to be maximized,
as well as to some research problems which require essentially integrated research
effort .
Behavioral-social sciences are those which relate to social, cultural,
psychological, political and econonic aspects of population. Vfhile the disciplines
involved can generally be derived from the adjectives above (i.e.. Sociology,
Anthropology, Psychology, Political Science, and Economics), also included are
the basic population science of Demography, which cross-cuts other disciplines
(particularly Sociology and Economics), and disciplines which are nevrly emerging
in the population field, such as Geography. A listing of disciplines is not as
iraportant as is the fact that all of them are involved in disciplinary, inter-
disciplinary, and multidisciplinary study of population processes cited earlier
(popiilation gro\rth, change, decline, distribution, and, as well, fertility,
mortality, and migration).
Psychological research focuses on both individual and couple behavior and
on societal concerns. We believe that psychologists have particular competencies
for conceptualizing and conducting uniquely psychological studies as well as
complementing and enhancing biomedical research. The basic content and principal
concepts of psychology pertain to an unders1;anding of behavior and behavioral
change. Toward such understanding, we are concerned with the notives , attitudes,
values, personal- orientations, and competencies which underlie or are associated
with behavior and behavioral change. To study these diverse processes, we are
trained in special research, methodological, and analytical skills. While we do
not over-value our interests and skills in relation to those of other disciplines
and do not hold that only psychologists sho\ild do research on psychological
81
problems, we believe strongly that psychologists have a very inportant place
in independent and collaborative population research.
It may be useful to state an exajnple of the kinds of issues which require
cooperative interdisciplinary research. Biomedical scientists have made major
advances in recent years in the development and evaluation of various contraceptive
techniques. It is our contention, hov/ever, that the availability of the most
effective, safest, and least expensive contraceptive possible will have little
impact on fertility it it is not use'd. It is within the realm of psychology,
to develop a fuller understanding of individual and couple decision-making
processes, motives, attitudes, and values which may explain the acceptance or
rejection of a contraceptive techniq^ue, and to use this understanding to generate
greater use or encourage the development of more acceptable contraceptives. In
the case of contraceptive development, it should be added that a psychological
specialty, psychobiology, has competencies and training in the interaction of
neuroendocrine and behavioral processes relating to fertility, fertility regula-
tion, and contraception.
III. Current and Needed Population Research in Behavioral -Social Science Areas.
In tu-rning to research issues, we would first like to refer briefly to
three areas of research which are more traditionally dealt with by behavioral-
social sciences, and then turn to four areas of research which we believe to merit
intensive psychoipgical as well as multi-disciplinary attention, including that
of the biomedical-sciences.
The three research topics to which we. wish to refer briefly are: Population
Change, Population Charactersitics , and Mortality. As traditionally approached.
82
these are more vithin the domain of sociological der.ographers , but there are
certainly contributions which researchers from other disciplines can make.
A. Population Change
Research in this area has involved historical analysis of and projection
from population trends, and societal consequences of change. Studies of trends
have produced much innovative work in the development of measurements and mathe-
matical models. Studies of consequences have focused on economic, political, and
societal well-being in relation to environmental impact and nattiral resources
and, in the larger sense, on the relation of all of these to population growrh ,
stabilization, and decline,
Wliile demographic and mathematics specialists contribute the bulk of research
in this category, research by all behavioral-social sciences is needed, parti-
cularly on consequences of population change. In addition, a.n ur^der standing of
contraceptive utilization is required.
B. Population Characteristics
Research in this area has been largely comparative, focusing on rural-urban
and ethnic-racial contrasts in population change and composition. Research has
incorporated cultural, historical, and economic developm.ent and has focused on
the association of population characteristics with such factors as social behavior,
human territoriality, and economic situations.
There has, as yet, been little research em.phasis on the impact of various
population characteristics (race, sex, socio-economic status, and so on) on
mental health and psychological stress, nor has there been sufficient research
on the impacts of migration and population distribution or fertility changes on
83
population characteristics or on societal services demands. Again, in this
category, much of the research has been demographic in nature, with a sprinkling
of ethnographic and political studies. There is a need for greater input from
those concerned with psychosocial and bionedical aspects, particularly on health-
related issues (including maternal and child health) in various sub-groups of
the population.
C. Mortality
Little supported research was done in FY 197*+ in this category. Most of
that which was done was demographic and/or methodological (pertaining to collection,
tabulation, and analysis of data on death), with some emphasis on sex and/or racial
differentials. There is much more that can be contributed by epidemiologists and
medical researchers, not only in the area of mortality, but also on morbidity.
Relative to the above three topics, we feel that ps;/-chosocial aspects have
generally been neglected. Since most of the research has used aggregate (societal
and sub-group) data, we still know very little about micro-level (individual,
couple, and family) processes.
Four remaining topics to be considered are: Migration; Contraception,
Abortion, and Sterilization Use and Effectiveness; Teen-age Contraception, Preg-
nancy, Abortion, and Term Deliveries; arid Marriage, Divorce, and the Family. We
believe that these topics require greater research attention, not only by psycho-
logists, but by other behavioral-social and biomedical sciences.
D. Migration and Population Distribution
Much of this research has been demographic in natoire, involving census
tabulation and historical trends. There has been some anthropological work using
participant observation and interviewing techniques. V/ithin the past few years.
8k
there has been an increasing focus on the adjustnent and assimilation problen-.s
of migrants, and on associated psychological and economic costs.
On the whole, this is a much neglected area of multidisciplinary research.
Perhaps because of this neglect, the research focus has been largely at the
aggregate level, vith little emphasis on individual, dyadic, and fam.ily processes.
More importantly, the interrelationships between mobility, family formation, and
childbearing and, in turn, the impact of these interrelated processes on public
policy have been largely ignored. It is also interesting to note that costs to
migrants are heavily emphasized, while benefits to then (such as occupational
mobility and income equalization) have been given little attention. In addition,
research pertainirf, to costs and benefits for non-migrants has been essentially
non-existent.
From, a psychological perspective, migration reflects decision processes by
the couple. Intrapersonal factors, such as intelligence and efficiency in seeking
and evaluating information, motivations, and goals and aspirations are present in
migration; so also aj-e interpersonal influences, from simple information depen-
dence to overt conformity pressures. Several psychological models of migration
decisions and behavior (presented by Wolpert, 1965) reflect the individual and
psychosocial natiire of migration decisions; an understanding of these processes
is essential if aggregate behaviors are to be \inderstood and effective policies
relating to migration are to be developed.
E. Fertility, Contraception, and Sterilization
Despite increasing research activity on these interrelated issues, they
are as yet insufficiently understood. We would like to refer to two issues in
85
this category: (l) contraception, abortion, and sterilization counseling,
availability, and effective use; and (2) teenage pregnancy, contraceptive use,
and abortion.
1 . Contraception, Abortion, and Sterilization Counseling, Availability ,
and Effective Use .
These issues have received a substantial anbunt of research attention
by demographers and epidemiologists. However, ve remain poorly informed
concerning the decision making process of the couple (and research in-
volving both members of the marital dyad has been sparse), nor has there
been much more than a beginning toward understanding the multiple, complex,
and interrelated factors which underlie repeated and continuous decision
making.
There is need for research on the cultural and psychosocial factors
within the life situation of the individual and the couple. There is a
need for assessing not only known contraceptive and biological infor-
mation, but also the attitudes, motivations, personality characteristics,
and social factors which affect population decisions. These include
early marriage, sexual activity, contraceptive use, fertility planning,
abortion, and sterilization. V/e need to understand the impact of all
these psychosocial factors on acceptability and acceptance or rejection
of fertility regulation techniques and their psychosocial consequences.
One issue in this category which was raised in a recent report by
the Institute of Medicine, National Academy of Sciences (1975) pertains
to the concern of some policy-rnakers and citizens that legal abortion
will become a more prevalent form of birth control. The report by the
Institute of i'!edicine notes that a 197^ review of the situation suggests
only that verj-- United data exist in the U.S. mostly because legal
abortion has been videly available only since the January 1973
Supreme Court decision- This is obviously an important issue, and
one vhich bears continued r.onitoring. Greater vmderstanding is reauirec
of the characteristics of acceptors and rejectors of diverse means of
fertility regulation and of the possible vays of facilitating improved
contraceptive practice.
2. Teenage Contraceptive Use, Pregnancy, end Abortion
Sexual activity is increasing among vmnarried teenagers, who are also
identified as the least effective contraceptors (F^resser, 197^). While
ignorance of fertility-regulation methods has been repeatedly demonstrate:
there has been little attempt to conduct in-depth studies of perceived
vulnerability to pregnancy or of the complex set of situational,
psychological, and interpersonal factors vhich lead to or preclude the
seeking of contraceptive protection by teen-agers.
The high, linprotected sexual activity has led to an increase in out-
of-vedlock pregnancies and abortion among this group: teenagers are
reported to constitute the highest proportion of late abort er s , vith
concomitantly higher risk (Tietze and Dawson, 1973); Teen^-age out-of
wedlock pregnancies have nearly doubled in the past decade, vith high
risk for infant and maternal mortality (Outright 1972). Carrying a
pregnancy to term generally involves leaving school early, possibly
rushing into marriage — vith the high probability of subseq^uent divorce,
and the likely disruption of the female's entire personal and productive
life (Russo and Brackbill, 1972). The consequences for all involved
87
— the mother, the father, the child, and society — are inestimable
(David, 1972).
We know relatively little about the deteminants and consequences
of contraceptive use, abortion, or tern pregnancy decisions in this
important group. We thus are not able to delineate neans of changing
behaviors or dealing with possible outcomes. Further, no adequate
policy decisions concerning contraceptive and reproductive education
and services can be developed until \ie have more research findings.
The need for comprehensive and nultidisciplinary research is nowhere
more urgent than in this area.
F. Marriage, Divorce and the Family
While research en topics in this area has increased, there has been in-
sufficient attention to the complex set of psychosocial problems associated with
the above factors. Government support in this area durini^ FY 197^* included
studies of marital intensity, household formation, occupational structures,
labor force participation and fertility, family size and spacing, female roles
and m.arital disruption, changing patterns of first marriage, and delayed child-
bearing. We believe that there is yet poor understanding of a number of issues
in this category; we would like to refer to two issues: V,'omen's Poles, Labor
Force Participation, and Fertility; and Feimily Size and Spacing.
1. V/omen's Holes, I^bor Force Participation, and Fertility
In our society, we are currently seeing fertility reduction in the
presence of changes in the societal status of women and increasing
participation of women in the labor force. However, we are not yet
able to predict the long-term i-^pact of changes in women's status
88
or increased labor force participation on fertility, and fair.ily
fomation patterns or on population (rrovth. Further, ve have
little understanding of the trade-offs between vork (or careers)
and fertility. A number of behavioral-social scientists are engaged
in research directed at assessing the perceived comparative rewards
and costs and the psychoeconomic values of children, particularly
in relation to alternative roles- In the past, nost such research
utilized aggregate socioeconomic models (Easterlin, I969), recognizing
the iinits of such aggregate models in predicting to individual
behaviors.
There has been relatively little research, but some theorizing,
about the possible effects of policies which assure women rights to
careers and childbearing, through such things as guaranteed maternity
leaves and fully adequate day care centers. In fact, genuine alter-
natives to childrearinp and completely dual work and childrearing
roles have so recently been assured that, at present, the possible
consequences can only be matters of speciilation. Further, rapidly
changing patterns in divorce and remarriage may have unexpected
effects on population gro^-rbh , composition and distribution. Thus,
careful and thorough research on these issues would appear mandatory.
2. Family Size and Constellation Factors
Despite the fact. that current fertility portends a predominance
of two children families, present data suggest that the tv:o-tc-
four-child range remains the ideal, an ideal which has existed in
the U.S. at least since the lQ?,0's (Blake, I966). As noted earlier.
whether current rates nerely reflect economic conditions or do
suggest genuine change cannot as yet "be determined; data from
current college students (Thompson, 197^) and from Europeeun
studies (Blake, 19^5 ) night lead us to believe that the phenomenon
is ephemeral and related to economic structures.
V7e do know that certain family patterns, such as the only-child
and widely spaced children, are not highly valued in this culture.
We have some evidence that this view is not based on behavioral
observations. For example, only children and children in sm.all
and widely spaced families tend to be superior in intellectual
development and in the acquisition of independence and autonomy.
We axe not certain what leads to such superiority; it may derive
from socioeconomic, genetic, maternal physiological, or other
factors, or some combination of these. Definitive findings could
have untoward policy outcomes (particularly -should genetic factors
be demonstrated unequivocally to be causal). Another possibility
is that observed differences evolve fron differential opportunities
for nurturance of desirable qualities and/or, perhaps, prenatal
factors in closely spaced families; if confirmed, dissemination of
such findings should lead to individual — ra.ther than policy in-
flicted — changes in family forrnation.
Because of negative attitudes concerning the only child and the
continued preference for 2-U children, we could only predict that
optimal growth patterns would be maintained if we knew the extent of
intentional childlessness which would occur in the future and the
90
Beans of developing positive attitudes about one-child families.
These too remain unknown, and thus require further research.
G. Population Policy
Population policy has been referred to throunhout this report, but ve
vould like to turn briefly to the need for research on population policy per se .
As is no doubt known, worldwide concern about population problems led to the
designation of 197^ as World Population Year. During that year (August, 197^4)
the Bucharest World Population Confefence was convened by the United Nations
The Plan of Action adopted by the 135 governnents at the Conference and subse-
quently approved by the U.K. General Assembly contained many important propositions.
Among them, the following are particularly .significant: (l) deciding on the number
and spacing of one's children is a basic human right; (2) governments should provide
individuals the information and means to exercise this right; (3) population
policies and programs should be part of development planning; {h) quantitative
goals and time tables for reducing population grovrth and mortality are desirable;
(5) improving the status of vom.en will help to reduce population grov-th ; and
(6) reducing population growth and promoting socioeconomic development are
mutually reinforcing and together lead to a higher quality of life (V.TC, l'^7'»).
Both exp].icitly and implicitly, the Conference thus yielded recommendations for
ptopulation policy.
"Population Policy" is rarely defined, and tends to have different meanings
for members of the various behavioral-social sciences, bio-nedical specialists,
politicians, and population planners. I-'ajor focus has been on reducing fertility.
Any governmental policy of fertility reduction represents a national decision
to influence large numbers- of people, via establis!ied mechanisms for achieving
91
desired change. Governmental policies are, in the r.ain, on the societal level
— as improved education, better nutrition and health services, higher incone,
alternative societal roles for vonen, and other benefits of socioeconoiTiic
development. However, as f!cOreevey (197^^) has noted, "the overarching problen
in population policy is how to turn public objectives into private actions'".
That is, a societal program can have an effect only insofar as it directly or
indirectly brings about changes in individuals and couples; for exam.ple, only
if marriages are delayed, family size is reduced, and pregnancies are avoided
will a societal fertility policy have achieved its goal.
While the Bucharest Conference provided valuable interaction between
behavioral-social scientists population policy makers, and government planners,
reports of the Conference suggest that available research findings are seldom
considered in reaching consensus on population policy formation and implementation,
and that scientists are insufficiently involved in conducting research of
immediate utility to policy m.akers oriented to population policy goals.
In a UH Economic and Social Commission for Asia and the Pacific Conference
(197'*) on high priority research by the social sciences, in order to provide
necessary input for governmental policy makers, the following topics were stressed:
inforraation, education, and comm.unication strategies; perceptions, attitudes,
and beliefs of service providers; and clients' reactions to alternative delivery
systems. All of these relate specifically to social science research needs and
linkage to fertility-related policies.
In the area of fertility, as well as in other population areas, many research
and policy questions v:ith relevance to this and other countries have been cited
92
in this report. It is recognized that each country must develop, its ovn set
of policies "based on analysis and resecrch viable to its o\m setting, and that
policy-makers and researchers vithin a given country will have to develop a
coramon perspective in the identification of key questions that are researchr.cle
and need to be answered ( cf. Sinmons and Sanders, 197^). In our country, it is
thus imperative that governnent agencies and research scientists frcn multiple
disciplines perceive the population research questions which relate to our ovm
particular probleics. While research findings in this country will no doubt serve
other countries as well, the degree of collaboration on research problems unique
to other countries must also be repeatedly assessed.
Federal agencies recognize the need for Dolicy-related research, and have
supported national and cross-national efforts. However, there has been a gradual
decline over the past few years in support of the few projects in this area. At
the sane time, there is a recognized need for topical (as internal migration)
and comprehensive (as the effects of public policies on fertility) disciplinary
and inter-disciplinary research. As in all other areas, the reasons for individual
acceptance or rejection of policy guidelines and the means of creating acceptance
when policies beconie essential both require much research attention.
IV. RecoFJnendations
A. CoTmnxinication
Throughout the preceding text, we have stressed the need for collaborative
and complementary research on population issues. In discussing policy, we also
noted the lack of and the need for conr.unication between researchers and planners
and utilization of available research findings. We believe that a great deal more
93
interdisciplinary/' connunication is also desirable. There are, of course,
disciplinary and interdisciplinary Journals (sone with federal support) in
vhich population-relevant publications appear; the latter tend, however, to
include behavioral-social or_ bionedical reports. The APA Division of Population
Psychology has recoranended and explored the estabilsh-tient of a broader intei'-
disciplinary journal of population, which could include publications in behav-
ioral-social and health sciences.
Research information might also be disseminated by government agencies.
For example, in addition to annual surxiary reports of funded research, it might
be possible for agencies periodically to prepare and nake available one page
abstracts or summaries of completed research. In addition, to encourage cross-
disciplinary contact, information exchange, and evaluations outside of disciplinary
lines , a greater number of conferences and workshops might be organized on topical
issues (e.g., fertility regulation, migration, and so on). Such conferences
would be even more useful if participants included policy makers as well as
scientists from diverse disciplines.
There is also a need for dissemination of research findings to the general
public. Attempts should be made to maximize public knowledge of population and
family trends, particularly when findings are highly reliable. Only through
public awareness of — and agreement with — policy goals can these goals be
realized.
B. Research Support
Governmental agencies have attempted to maintain a balance between targeted
and grant research, and to assure that research areas of national priority receive
94
attention through targeted research. Research needs are assesserd by goverr_T.ent
in collaboration vith scientists and representatives of the public. V.'e endorse
the substantial support of both basic and applied research, since the former
determines the strength of the latter. V,'e recOTnend an increase in the proportion
of federal funds allocated to the behavioral-social population sciences and to
collaborative cross-disciplinarj"- research.
C. Scientific Trainir.f; and DeveloTinent
Government agencies have contributed to the training of behavioral scientists.
However, since the only veil developed academic prograns in population study are
in Sociology and Economic Deinography, training funds have gone principally to
these areas. There are still very few faculty trained in population in other
behavioral science disciplines. Therefore, ve reconmend greater training on the
post-doctoral level, with a graduated increase in doctoral-level training as nore
faculty develop expertise. The American Psychological Association Board of
Scientific Affairs has a small program to encourage nev.'ly emerging research
areas, especially interdisciplinary ones.
Since population represents a unique interdisciplinary field, and inter-
disciplinary training has not been advancing at a very great rate, interdisciplinar:-
training programs should also be considered. However, to our knowledge, there
are few universities in the country which have sufficiently broad faculty involve-
inent to develop such a progran unless Federal sponsorship helps bring about such
an involvement.
^ • Ethical Issues
been
Psychologists have traditionally/conr-itted to high ethical research standards,
and have developed guidelines for this purpose. Ve believe that the focuses of
95
population research, both biomedical and behavioral, and the. potential use of
research findings in policy development (particularly in education and attitude
change areas) make it essential that there be continual awareness of individual
and social values as well as assuring full protection from physical and psycholo-
gical ham to all persons contributing data in research projects.
V. Conclusion
We believe that the psychological components of all research questions in
population are crucial and central, since individual, and dyadic psychosocial
processes underlie and shape population-related behaviors. The number of
psychologists involved in population study remains small but, as the attached
report indicates, the commitment of the few has done much to advance the interests
of many others . V/e know we need more psychologists in this important area of
research; even more importantly, we need more research on the psychosocial factors
underlying population behaviors. It is especially important that population
research be interdisciplinary in nature, and that the government maintain a
focal point for stimulating and supporting population research which would involve
all the population-related sciences.
96
Reprinted from American Psychologist, Vol. 27, No. 12, December 1972
REPORT OF THE TASK FORCE ON PSYCHOLOGY,
FAMILY PLANiMNG, AND POPULATION POLICY
APA TASK FORCE ON PSYCHOLOGY, FAMILY PLANNING,
AND POPULATION POLICY >■
THIS report summarizes the activities of the
APA Task Force on Psychology, Family
Planning, and Population Policy over the
past two-and-one-half years, identifies trends in
population psychology, and recommends actions to
be taken by the American Psychological Association,
by psixhoiogj' departments, by individual psycholo-
gists, and by other agencies and persons interested
in encouraging the development of this relatively
new field.
The Task Force, established in October 1969 by
resolution of the APA Council of Representatives,
v.-as charged wiih reviewing psychological activities
related tc population and wiih making recommenda-
tions to stimulate participation by psychologists in
pcpuiation-related research, training, and service
acti\iiies. The Council, by this action, was re-
sponding to the increased awareness among psy-
chologists that professional expertise should be ap-
plied 10 topics of current social concern and sig-
nificance; population psychology represents one
major e.\amplc of such a topic.
As of this v.-riting (September 1972), the Task
Force considers its mission only partially accom-
' The members aie Henry P. D.ivid (Chairman), Jarres
T. Fawcett, Deborah Mttory, Sidney H. Newman, Edward
T. Pchlman, and Vaida Thompson. Miriam F, Kelty
srrve; as AP.\ staff liaison.
The Task Force is grateful for the dedicated support of
.APA staff, initially by Leslie Hicks and subsequently by
Wiriar; F. Kelty and ner associates in the Office cf Scic-ii-
tjfic .Affairs, Marsha Pa'ticr, Willo White, and Judi Stud-
sirup. Thc\ would also like lo thank The Population
Council, The Center itir PopLlilion Research (National
Institute of Child Health and Iluman DevelopTr.cnt>, the
In.'tilu'c of Personality .^ssessnicnt and Research lUni-
vcrsi'.y cf Califpma at Berkeley), ?r,d tho Ui.-versitv of
.\orth Caroli.-,.!, ai! of which cco'^raled in d..'v>!opiii,:,
orf^nLiin;. ard inip!fir'er.;ini: workshops sponsored or co-
spoiisoreii b\ the T2.=.'; Force. In adr:il;on, the Task Force
has f'jrther benefited ir':~ the coun.-il of its consul'ants:
Catherine Ch'Iman, Harrison Go^gh, Minii Keiffer, Janette
Ilainwatir, M. Brewster Smith, and Helen Wolfcrs.
plished. To move psychology toward productive
interaction with other fields involved in the multi-
disciplinary area of population requires a long-term
effort which, by definition, exceeds the time con-
straints imposed on a task force. If the momentum
already established is to be maintained, it is the
conviction of the Task Force that the APA should
establish a Division of Population Psychology.
Task Force Activities
When the Task Force held its organization?.!
meeting on December 17, 1969, fev/er than a dozen
of this nation's more than 31,000 psychologists were
estimated to be working primarily on population-
related endeavors. In recognition of this deficiency,
the Task Force, with the support of the Population
Council, convened a workshop on March 6. 1970, at
APA headquarters in Washington; its purpose was
to review current activities by psj-chologists and to
discuss the roles they might play in the future. -
First issued in October 1970, the Task Farce
Newsletter is now mailed to over 7. SO individiiaii
and organizations. This Newsletter constitutes a
mechanism by which interested colleagues may ex-
change information.
The sponsoring of symposia ?t APA conventions
has been anotlier expanding Task Force activity.
From a single symposium at the 1970 j\Iiami Be,~ch
Convention, the number grew to 11 at the 19/1
-Washington Convention, all of them attracting,
sizable audiences. Ten sjTnposia, listed iu ,1 pic-
Convention issue of the Newsletter, were held r.t
the Convention in Honolulu. With the coopcraiion
of the APA Convcnticn Board, it v,'as possible to
schedule these meetings consecutivelj' so thai they
would not conflict with oi^e another.
-\ report on this wpikshop as well as ai! appc-id'-ios
referred tc in this report r.re available iip^-n request '.: 'ni
the Offite 01 Scientific .•\tf.-'.'rs, AmcricTii r-sycholoi-i.-.d .'•.--
sociatiun, i200 Seveiileenlh Slrcet, N.W., Wasiiincion, D.C.
-'■3036.
100 • rrLCr.\:vT.K 1972 • A^.•:KK■A^; Psvc;
97
Supported by The Population Council, a Con-
ference on Piychological Meaauremenl in the Study
of Population Problems was held in February 1971.
Cosponsors were the Task Force and the Institute
of Personality Assessment and Research (IPAR) of
the University of California at Berkeley. Deliber-
ately designed to be interdisciplinary, the Con-
ference attracted participanl5 from anthropolo.ay,
demography, sociology, obstetrics-gynecology, psy-
chiatry, and public health, as well as from sub-
specialties of psychology. (.-Xn overview and a
resume of individual papers, edited by Harrison G.
Gough, are available from APA as Appendi.x A.
See Footnote 2. The full proceedings are available
from IPAR.)
In October 1971, the Task Force joined with the
Center for Population Research of the National In-
stitute of Child Health and Human Development
in sponsoring a workshop at the University of
North Carolina at Chapel Hill (NICHD/UXC
workshop). The workshop focused on ideas for de-
veloping and educating psychologists to work in
the field of population; it included among its par-
ticipants not only psychologists currently engaged
in teaching or research in population but also the
chairmen or representatives of psychology depart-
ments interested in population psychology. (Ap-
pendi.x B, available from AP.-\, is a summary of the
proceedings, prepared by Vaida D. Thompson and
Sidney H. Newman. See Footnote 2.)
Interest in the field of population psychology has
been stimulated by the publication of such books
as The Psychology of Birth Planning by Edward T.
Pohlman (1969). Psychology and Population, a
monograph by James T. Fawcett (1970), filled the
need for a summary of the current status of be-
havioral research issues in fertility and family
planning. Interest among psychologists was aroused
further by three papers appearing in the American
Psychologist (January 1972); (a) a Task Force
repo'-t on "Population and Family Planning; Grow-
ing Involvement of Psychologists," (6) "Ethical
Implications of Population Policies" by M. Bre'.vster
Smith, and (f) "Support for Psychologists in the
Population and Family Planning .Areas" by Sidney
H. Newman and Miriam F. Kelty. in association
with the Task Force. (Tiie thi.-d paper is available
also from .Al'.\ as .\ppcndi.\ C; sec Footnote 2.
Reprints of the first two are available from .-XP.X.i
In addition, as a result of Task Force encourage-
ment, Psychological Abstracts ha^ given partial cov-
erage to the field, and the 1972 APA Survey of
Psychologists includes the category of population
and family planning. The Task Force helped to
develop a special issue of the Journal oj Social
Issues devoted to population policy. Finally, on
the initiative of the AI-'A Board of Scientific Af-
fairs, the Social Science Research Council cur-
rently is considering the establishment of an inter-
disciplinary Committee on Population.
Trends
In Fawcett's 1970 survey of Psychology and
Population, he pointed out:
\ population is made up of people, and psychology is
the study of people. Yet, there have been lew historical
intersections between demography, the science that studies
people statistically, and psychology, the science' that studies
people behaviorally [p. 1].
Since that statement was written, the situation
has improved somewhat; The number of psycholo-
gists involved in various aspects of population work,
though still small, is increasing; psychologists have
established better communications with demog-
raphers and researchers in allied fields. Nonethe-
less, population psychology is still in its infancy
and needs continuing nurturance if it is to mature
into a healthy and independent specialty.
It .=hould be understood that population science
is more than the study of population growth or
fertility control. It also covers such areas as migra-
tion and urbanization, mortality, and even under-
population (as in the well-known Indianapolis
Study — Kiser, 1962). The scope of population sci-
ence is suggested by the following definition, which
encompasses the psychological aspects of the field:
Population research comprises studies of the nature, de-
terminants, and consequences of population characteristics
and d.^namics and the development of basic data and
methods for such population analyses. Physical, biological,
psychological, cultural, social, economic, geographic, his-
torical and political factors may all be included in popula-
tion studies Operationally useful subdivisions of the
rield are:
a S.^stemaiic description of population characteristics and
dyn.TTiici i,-,c!udi.ng fertility, mortality, and nii::ration; of
Ccoirraphir distribution and socio-ecnnoniic ccmposition:
ir.ri ji vjrious c-jrreJates of different dcmusraphic rates.
L '^lulii- 01 tiie biolorical, psychological, social, and
en' irnnrni r;:.^! dftrrrr.irjKls of population cluractcrLitics
a.-d ri;.f..i-.-,ic=. and oi the eh'ccts of efforts to iniluoncc
demo;-jpl;ic rates,
c. ^ludi-S o! the con^rqucncrs of population character-
Ui.c.^ jnd dynamics, at botri personal and societal !-j\eIs.
Am
;'~AN' }';VCHOLOCIiT ' Df.ce.mber 1972 • 1101
98
wiuh attention to technic.il, intluitrial, economic, politic.il.
psychological, iocial. environmental, educitional, hc.ilth, and
related factors [Ottice of Science and Technolojy, 1972,
p. iOl.
A recent voltime entitled Psychological Perspec-
tives on Population, edited by Fawcett (1972),
surveyed and analyzed selected population topics.
While it lies beyond the scope of this report to re-
view substantively the trends in population psy-
chology., a few summary observations may be useful.
First, the chief contribution of psychologists has
come through their identification of the personal
and attitudinal variables related to fertility, par-
ticularly to family size. Some studies have focused
on fertility-regulating behavior and on the decision-
making processes of couples. Research has come
to emphasize more and more the normative rather
than the pathological sequelae of contraception and
of pregnancy termination. Increasingly sophisti-
cated, these studies promise to deepen our under-
standing of the determinants of human fertility and,
at the same time, to extend the research parameters
of motivation theory, decision making, learning,
and measurement.
Second, psychologists have tended to neglect such
issues as the psychological effects of family size and
of unwantedness on both children and parents; the
antecedents and consequences of migration and
urbanization; e\oi',ing f.imily lite styles; and the
impact of lower infant mortality and of longer life
span on the perceived value of having children.
A third point is that the search for the social
and psychological factors that explain variations in
fertility has not been very successful. At the IP.-\R
Conference cosponsored by the Task Force, the dis-
couraging results of earlier efforts were attributed,
in part, to the use of measures less valid than others
now available and to the undue attention paid to
variables only peripherally related to family plan-
ning and fertility-regulating behavior. It was fur-
ther agreed that adding a few more personality and
ability tests to the battery currently in use, and
then seeking "corrolHlc-," is not the answer. What
is needed are new nie:isurcs of variables both the-
oretically and f^pipiri::.',!!)- relevant to far,Miy phn-
ning and new itiethiii^ of ."inalysis that give i^'^eator
atteatio;; 'o the pc. ert'ii! interpersonal d-ncrminants
of fcrtilitv-rogulati'iL' b:-'ha\ior. Mea^ll■-e^ th.n: pre
relatively simple, brief, easily administered, and
tia.-.snationnll) :id:iptat)!c' a;o particulaily desirable.
E,\amples of such measures and of appropriate ana-
I3 tic techniques are given in Gough (1972).
Finally, a Task Force questionnaire indicated
that, though interest in population psychology is
growing rapidly, practically none of the psycholo-
gists currently working in the field entered it di-
rectly upon completing the doctorate; indeed, at no
higher education institution in the nation is there
a psychology department with an uiidergraduate,
graduate, or postdoctoral program e.xplictily dealing
with population. Consequently, few psychologists
are prepared to teach or to do research on such
broad topics as (a) theoretical-conceptual frame-
works of population research, training, and services;
(b) the roles of individuals and groups in such
phenomena as se.x and reproductive behavior,, fer-
tility regulation, migration, family formation and
structure, policy development, and population edu-
cation; or (c) methodological approaches, includ-
ing psychological measurement, to the study of
population.
The summary report of the NTCHD/UXC work-
shop (.Appendix B; see Footnote 2) incorporates
suggestions about leaching, curriculum development,
and other training activities (e.g., laboratory, field,
and clinical v.ork) in population psychology at the
undergraduate, graduate, and postdoctoral level.
Underl\ ing all discussions at t-he Chapel Hill work-
shop •'\as the belief that each psychology depart-
ment must consider the matter of training students
for such work in the light of its own programs and
goals, as well as in relation to the resources and
objectives of the institution as a whole.
Turning to the difficult area of population policy,
the Task Force concurred with M. Brewster Smith
(1972) in his statement that,
.Any consideratio.-. of ^"plicit population policy lands us
squarely in the realm of political and ethical issues — politi-
cal because competing interests are at stake, ethical because
ive have to assis-i priorities to competing values, lo arrive
at accommodations betuecn competing standards or criteria
of evaluation. Issues of political ethics — 0: uho ouptt to
get what, where, and ^.^..-n according; to v. bar substantive
criteria or procedural rules — are central and e.\cecd:n!;I>
difficult [p. 111.
The complex problem of what constitutes an "op-
timum" poj.iiilalion. for instrnce, is a policy issue
of central concern, deserving the attention of ps\--
chologists nnd oilier social scientists. Unless tht
p.sychosocial aspects of population behavior an
identified' and explored, peipiilation planning and
Dkcfml
.•\.'.ir.uiL.\.\ rsv( !to:.C'':;is";
99
policy makinc; will not have the benefits of a firm
empirical u'roundini; and of the insights into indi-
vidual behavior that psychologists are best qualitied
to provide.
The Task Force is convinced that population is
a proper, legitimate, and necessary area for psy-
chological study. The study of population has a
need for psychology because at present, as various
facets of the field are examined, significant gaps in
psychological knowledge become quickly apparent.
If psychology cannot contribute to a belter under-
standing of why people want children, how can it
claim to be concerned with the centrally important
dynamics of human behavior? If psychology says
little about why people migrate or why they live
where they do, and about how this affects their
life styles, how can it claim to have an abiding
concern with the full range of societal issues?
Conversely, the Task Force feels that psychology
as a science will benefit fro.Ti the growing interest
in population-related research in that its perspec-
tives will be broadened and it will be able to assure
more diverse training, research, and service op-
portunities for present and future students. More-
over, the Task Force is convinced that psycholo-
gists, by systematically applying their scientific
resources, methodological skills, and professional
talents, can contribute significantly to an under-
standing of important social issues. Population psy-
chology is neither a "cause" nor a "fad." It is a
field that should be of enduring interest and con-
cern to psxchologists.
Recommendations
The following recommendations (not presented in
any order of priority) are based en the Task Force
conclusions that (a) psychology has a vital con-
tribution to make to the multidisciplinary area of
population; (b) psychology will benefit from a
close involvement with this area; and (r) mecha-
nisms already exist, or can easily be established, for
systematically developing population psychology as
a productive area of scientific research, training,
and professional service — an area responsive to
emerging social not-ds.
1. All A PA iJiiiilon oi Population Psychology
s/ioiild lie established. If enough .-\PA members
are interested, a Divisiun of Population P.-,ychology
could be established to continue many of the ac-
tivities ir.iti.^ted by '.he Tusk Force. These would
include disseminating a Ne-Li>sletter, arranging pro-
grams at APA conventions, and sponsoring work-
shops and conferences funded from outside sources.
Such a division would also elect to the APA Council
representatives who would, together with other
elected officers, have a voice in APA aft'airs. foster
APA activities in the area of population, and fa-
cilitate continuing e.xchanges with other di:>ciplinej
interested in populaiion problems.
2. Psychological r-'search in population should
be encouraged. The Task Force — through its
Newsletter, convention symposia, and workshops —
has tried to stimulate research on a broad range of
population issues, some of which are outlined in the
statement from the Population and Reproduction
Grants Branch of the Center for Population Re-
search of the National Institute of Child Health
and Human Development (Appendi.x D; see Foot-
note 2 ) . The Task Force hopes that, as more psy-
chologists become aware of the interdisciplinarj-
nature of the population field, they will join with
colleagues from other disciplines in systematicailv
developing psychological research in population and
that such research will receive the necessary finan-
cial support from federal and private sources.
3. Interdisciplinary postdoctoral training should
be otjcrcd. The easiest and quickest way of train-
ing psychologists for w;ork in population is through
interdisciplinary postdoctoral programs. Such pro-
grams, tailored to individual needs, could be located
in university centers of population studies or in
other departments with appropriate staff and fa-
cilities. Postdoctoral fellowships are currently
available from the Center for Population Research.
National Institute of Child Health and Human
Development.
Doctoral -level psychologists who already have
some acquaintance with the population field might
benefit from brief and intensive summer institutes
which would give them opportunities for additional
interdisciplinary postdoctoral e.xperiences in the
field.
4. Graducte training should be onered. Graduate
education aimed at producing psychologists for work
in iiop.ilatiop. iv.'.ist ensure that sfj'ients r^xeive the
traipiii': e^M'nri.-'.l not only to estabiishin'- rl-.^ir
i(!fn;i'\ and c\pcri!;e as Ds\'cholo£cisis but al;o to
prov;fli:i;r conipeti-nce in the population area. \"ar;-
ov> apfj'-oaches to such doctoral training are ol::-
litiiil in the Report of the North Caiolini Wo.'-k-
sh'i;) (Appendix B: see Footnote 2).
Air:.Rrc.\;-. Psvchokkiist • Dece.mber 1972
100
Interdisciplinary traininf; programs could be de-
veloped that would permit graduate students in
psychology to take a broad range of courses, to re-
ceive diverse field experience, to specialize in a
population-related area, and to focus the disserta-
tion on a population topic. Such an interdis-
ciplinary program would provide an enriched scien-
tific and intellectual background, merging labora-
tory, field, and clinical work to produce new in-
sights and fresh approaches.
5. Undergraduate education should be ofjered.
Population psychology topics could be covered in
almost all psychology courses, beginning with the
introductory course. Such early exposure would
help to establish the undergraduate's perception
of population as a legitimate area for psychological
study; it might also lead writers of te.-itbooks to
include material on population.
Population phenomena could be dealt with in
such basic courses as e.xperimenta!, developmental,
social, clinical, and physiological psychology, as
v.-ell as in more specialized courses on learning, per-
ception, personality, tests and measurement, adoles-
cents, attitudes, small groups, etc. Examples of
suitable population topics are given in the Report
from the North Carolina Workshop (Appendix B;
see Footnote 2).
6. The interest of psycholoj^y faculty in pop-ula-
t:o)i should be ejtcoi'.raged. Psychology faculty,
working in concert with the proposed APA Division
of Population Psychology or other coordinating
agencies, might facilitate the development of (a)
population materials for inclusion in psychology
textbooks; (b) an introductory text organized
around a population theme; (c) a '"curriculum
bank" for the exchange of topical bibliographies,
reading lists, course outlines, and other teaching
aids; and (d) a "resource file" that lists who is
teaching what courses where, who is available for
short-term consultation, etc.
7. Psychological assessment methods should be
coordinated. The use of scales and measures that
o:her researchers have found valuable or promising
uiil help to increase and improve the poo! of in-
•-LTj-rt'.able dr.ta. One ixttractivc idea is the "core
ki'.." a brief ,<et of [)sy..liological measures that
ni,in>- investigators might at:ree to employ in chcir
nun pr.,Ject<, thus ensuring soiii;.-' linkiige to ether
work in the f^eld. (The individual researchei
uould. of cou.rse, be free to use whatever addi-
tional m.easures he felt were necessary to his par-
ticular investigation.)
Ideally, p.sychological assessment techniques
should be reliable and valid enough to be used in
transnational field studies. This means that they
must be adapted to diverse cultures, standardized
for local application, and then tested for their
utility in predicting selected behaviors. Further,
whenever multivariate psychological tools or test
batteries are used, clusters and combinations of
scores, as well as single variables, should be
analyzed.
8. A questionnaire and interview schedule bank
should be established. To facilitate the adaptation
and improvement of standard psychological assess-
ment procedures, researchers should be requested to
send copies of questionnaires, along with guide-
lines and normative data, to a central questionnaire
bank that might be coordinated by the proposed
.\P.\ Division of Population Psychology.
9. Psychological services should be strengthened:
(a) Counseling about birth planning should be
available to clients who request information or
assistance in coping with decisions about contracep-
tion, abortion, sterilization, artificial insemination,
out-of-wedlock pregnancy, family size and birth
spacing, voluntary childlessness, the psychological
aspects of genetic factors, adoption, and sexual be-
havior. (A) r«/i and other predictive instruments
should be developed to assess psychological reac-
tions to sterilization, abortion, and childlessness;
in addition, such instruments could furnish data
that would help a particular couple decide which
contraceptive methods are most appropriate for
them, (c) Sex educatian should be provided in
both formal educational and nonschoo! settings.
Such programs should be psychologically sound and
should follow principles of psychological develop-
ment, (d) Population education, involving a core
program of population dynamics in educational
settings, should be developed. The activities of
psychologists as population educators would range
from classroom instruction through research to con-
sultation with persons responsible for formulating
educational policy or administeriin.' ser\ice pro-
gran;s. (e) Proyrn,-,: cvjtuction — designed to pro-
vide rapid, rosrMrch-b.-ised feedback f.>r i-i'provinc
the quality of sfrviccs at clinics, schools, and other
population service centers — should be an integral
part of any program.
10. Ethics an.i social rcsponsibilif y in populition
.'4 • Dl.Cl:.MBEK 1972 • .Amh-kican P;
101
research should be emphasized. All research that
deals with human beings imposes on the investigator
an ethical responsibility to take the necessary pre-
cautions lor safeguarding individual welfare and
privacy and to avoid making claims and promises
that cannot be delivered. So it is with population
psychology. In research with selected population
subgroups, a thorough understanding of ethnic,
racial, religious, economic, and cultural factors is
essential. When an investigator develops research
protocols and implements field studies, he should,
if possible, consult psychologists or other social
scientists who identify with particular population
subgroups.
11. Research findings should be disseminated.
Important research findings should be communi-
cated in brief and readable form through appropri-
ate mechanisms. One such mechanism is the News-
letter, which should continue to be produced and
distributed to all interested persons. In addition,
consideration might well be given to the eventual
development oi a quarterly Journal on Population
Psychology.
12. Participation in legislative and program con-
sultation should be encouraged. Qualified psy-
chologists throughout the country who are prepared
to assist legislative and program-planning bodies in,
developing guidelines for legislation in population-
related fields (e.g., birth planning, abortion, steril-
ization, information and services to minors, out-
of-wedlock pregnancies and births, alternatives to
parenthood, and incentives and tax policies) could
be identified. Psychologists should be aware that
although they usually act as private citizens in such
situations, their activities are often perceived as
representing the scientific capabilities and ethics
of psycholog\' as a discipline.
CONCLUSTO.N'
The Task Force welcomed the mission entrusted
to it by the Board of Scientific .Affairs. Its en-
deavors were strengthened greatly by the small but
growing number of psychologists who are becom-
ing actively involved in population-related research,
training, and professional services. Conversations
Vtith colleagues in allied professions convinced the
Task Force further that psychologists could — and
are expected to — make significant contributions to
the multidisciplinary field of population. Their
hope is that the prompt organization of a Division
of Population Psychology and the gradual imple-
mentation of these recommendations will demon-
strate that psychology, in association with other
sciences, can continue to e.xplore all aspects of
societal problems and human behavior. The Task
Force invites fellow psychologists to join in e.xtend-
ing the frontiers of psychological knowledge and
capabilities.
REFERENCES
.\?.\ Task Force. Report oj Workshop on Psycltolcgists'
.4ctivities in Population. Washington, D.C.; .^j.erican
Psychological .Aisodation, June 1970.
.•\P.\ T.\sK Force. Population and family planning; Grow-
ing involvement of piychologists. .imerican Psychologist.
I9T2, 27, 27-JO.
C.^LiFOR.vu, University of (Berkelev). Conference pro-
ceedings: Psychological measurement in the study oj
population problems. Berkeley: University of California
Insw'.ute of Personality .Assessment and Research. 1972.
Da'^d, H. p., & KxLiY, M. F. (Eds.) AP.\ Task Force
Seii'ileiters. Washington, D.C.; .American Psychological
.Association, October 1970-72.
Fawcett, J. T. Psychology and population: Behavioral
reseisrch issues in fertility and family planning. Xeu*
York: The Population Council, 1970.
FiwciTT. J. T. (Ed.) Psychological perspectives on popu-
lation. Xew York: Basic Books, 1972.
CovcH, H. G. Personality assessment in the siudy of
popul.'.tion. In J. T. Fauxett (Ed.), Psycholc^i'zl pcr-
■fctiies on population. Xeu- York: Basic Book-. !9~2.
KisiK. C. V. The Indianapolis study of social and psy-
chological factors affecting fertility. In C. V. Kiser
(Ed.), Research in family planning. Princeton: Prince-
ton University Press, 1962.
Xiwin.v, S, H., i- Keltv, M. F. Support for psycholo-
gists in the population and family planning areas. Ameri-
can Psychologist, 1972, 27, 31-36.
Office of Scre.NCE a.vd Techxolocv, Executive Office of
the President. The federal program in population re-
search. Parts I and II. Report to the Federal Council
for Science and Technology, prepared by the .Ad Hoc
Group on Population Research. Washington, D.C.:
United States Government Printing OSce, 1969.
PoHL.M.A-V, E. The psychology oj birth planning. Boston:
Schcnkman, 1969.
5-\!nH. H. B. Ethical implications of population policies:
A piychoiogisl's vieu-. American Psychologist, 1972, 27,
II-I-
TiiOMPsuN. V. D., i Xewmax. S. H. Educating psycholo-
!;j:s fi.r v.ork in !:h:: popuiaticn neld: .A workshop re-
port Unpublished manuscript, available from .AP.A.
197;. (Mimeo)
.■AMERICA PsvcnoLOcisT " Dkcember 1972 • 1105
102
REFERENCES
P. 7 9 Kantner, J.F. and Zelnik, M. "Sexual Experience of Young Unmarried Women
in the United States," Family Planning Perspectives , Vol. 4, No. 4,
October, 1972, P. 10; "Contraception and Pregnancy: Experiences of Young
Unmarried Women in the United States," 1 Bio., Vol. 5, No. 1, Winter 1973,
P. 22.
P. 85 Wolpert, J. "Behavioral Aspects of the Decision to Migrate," Papers of The
Regional Science Association, Vol. 15, 1965, pp. 159-169.
P. 86 Institute of Medicine Report of a Study of Legalized Abortion and the
Public Health, May, 1975, National Academy of Sciences, Washington, D.C.
P. 87 Presser, H. "Early Motherhood: Ignorance or Bliss?" Family Planning
Perspectives, Vol. 6, No. 1, 1974, pp. 8-14.
P. 87 Wright, N. "Some Estimates of the Potential Reduction in U.S. Infant
Mortality Rate by Family Planning," American Journal of Public Health ,
1972, 62, 1130-1134.
P. 87 Russo, N. and Brackbill, Y. "Population and Youth," In. J. Fawcett (Ed.),
Psychological Perspectives on Population , New York: Basic Books, 1973.
P. 88 David, H.P. "Unwanted Pregnancies: Costs and Alternatives," In. C.F. Westoff
S R. Parke, Jr. (Eds.), Demographic and Social Aspects of Population Growth,
Vol. 1 of the Commission on Population Growth and the American Future
Research Reports, Washington: U.S. Government Printing Office, 1972,
pp. 439-446.
P. 89 Easterlin, R.A. "Toward a Socio-Economic Theory of Fertility: A Survey of
Recent Research on Economic Factors in American Fertility," In. S.J. Behrman
et al (Eds.), Fertility and Family Planning: A World View . Ann Arbor,
Michigan: University of Michigan Press, 1969, pp. 127-156.
P. 89 Blake, J. "Ideal Family Size Among White Americans: A Quarter of a Century's
Evidence," Demography , 1966, 3^, pp. 154-173.
P. 90 Blake, J. "Demographic Science and the Redirection of Population Policy,"
Journal of Chronic Disease , 1965, Vol. 18, pp. 1181-1200.
P. 90 Thompson, V. "Family Size: Implicit Policies and Assumed Outcomes,"
Journal of Social Issues , 1974, Vol. 30, No. 4, pp. 93-124.
P. 91 World Population Conference. World Population Plan of Action. Department
of State Bulletin , 30 September 1974.
P. 92 McGreevy, W.P. Et.al . The Policy Relevance of Recent Social Research on
Fertility , Washington: Smithsonian Institution, IPPA, 1974.
P-92 U.N. Economic and Social Commission for Asia and the Pacific. Report of the
Expert Group Meeting on Social and Psychological Aspects of Fertility Behavior ,
Bangkok: 1974, Asian Population Studies, Series No. 26.
103
REFERENCES (continued)
P-93 Simmons, O.G. and Sanders, L. "The Present and Prospective State of Policy
Approaches to Fertility," Prepared for the Ford Foundation Population
Meeting, Cali, Columbia, October, 1974.
P. 97 (Reference to attached report) APA Task Force on Psychology, Family
Planning, and Population Policy. "Report of the Task Force on
Psychology," Family Planning and Population Policy, American Psychologist ,
Vol. 27, No. 12, December, 1972.
\0k
AMERICAN SOCIETY OF HEMATOLOGY
TUSTBDNY FOR 'na; Pl^SIDLMr'S BI0M1IDIG\L PAMUL Septcml^er 30, 1973
I am David G. Nathan, M.U., Professor of Pediatrics, Harvard Medical
School and Pediatrician- in-Chief , Sidney Farlicr Cancer Center and Chief of the
Division of Hematology and Oncology at the Children's Hospital Medical Center
and Sidney Farber Cancer Center. I liave been asked to address the Panel en
behalf of the American Society of llematolog>', an organization of over J.UO'J
physicians and basic scientists interested in the study of the bicod aiid relief
from diseases of the blood.
Hie remarks submitted liere represent an extension of those subritted
by Dr. Oscar Ratnoff , President of the Society, on September 10 cf this year (attached)
Until very recently the Ajiierican Society of Hematology has played no
role in public policies that affect the funding of research in general and-
lienatologic researcii in particular. But in the past U^o years v,'e 'nave fel:
compelled as a Society to develop a public information conmittee capable of
presenting the Society's views on research affairs to administration officers,
representatives and senators in the Congress and to NIH administrators. V.'e have
developed tliis approach because we liave viewed certain recent aspects of MH
and federal policy witli real concern. V.'e believe that the recent turbulence ray
iiipair major advances tliat liave taken place during the past decade or two in cur
field. On the other hand tlie American Society of Hematolog)' is ver>' pleased
with the appointment of the President's Biomedical Researcii Panel. We agree
that some of tlie past doctrines concerning researcii policy and research funding,
held for years by many investigators, and NIH administrators need careful
examination to be certain that we approach the 21st centur>' with an intelligent
national medical research program. It is simple for an investigator such as
myself to say that if some research is good, more is better, but nore is not
infinite and reasonable planning and budgeting must be carried out.
105
1. Investigator originated versus targeted research . We must constantly keep in
mind tliat of the total liealtli budget of tlie United States only a very small fraction
is assigned to tlie researcli area, ^fost of us in tlie American Society of Hematology
feel very strongly that this small fraction sliould largely be spent in investigator
originated research programs, and that targeted projects of public interest and
great cost should be payed for out of the larger pool. For without adequate
funding of investigator originated research, the very ideas which stimulate a
public demand for targeted researcli will never emerge. A target cannot be
visualized unless the problem worth investigating is identified, and it is our
belief tliat tiie identification of problems can only come from relatively uninhibited
programs of investigator originated researcli. Surely it would have been most
unlikely for an administrator planning targeted research to have recommended the
screening of human sera for its capacity to agglutinate rhesus monkey red cells,
yet tliis investigation led to the diagnosis and eventual prevention of ]\h disease
of ■ tlie newborn. Tlie study of the serum of Australian aborigines would not liave
been seriously considered by a committee brought together to wage a war on
hepatitis, but such research has in fact led to diagnosis and prevention of one
form of this disease. It is unlikely that a panel of experts would have decided
to freeze plasma to determine the procoagulant activity of the precipitated
material which is ordinarily thrown away, but that material is now a major
resource for treatment of hemophilia. Only a rare physical chemist would have
considered the possibility that the addition of alcohol to plasma might separate
the plasma proteins from one another. That inquiry led to our ability to fractionate
plasma for specific treatments. I could go on and on with this list of the
contributions of fundamental investigation to clinical medicine. I have chosen
hematology as a model, and Ur. V.'introbc has eloquently presented another impressive
list to the Congress. The point is that you will hear from every investigator
that a broad program of undifferentiated investigator originated research must
106
be the strongest point in the National Institutes of Health. For without tlie
funding of clever minds, tlie discoveries will simply elude us.
2. Training . A most important obligation of tlie National Institutes of Hca'ltli
is to create and maintain a cadre of clinicians who are tliemselves investigators
and can apply the lessons learned in basic research to the patient. Most
important this cadre must be able to move in the otlier direction. They
must be sufficiently trained to investigate patients, discover new problems,
and by exposing and examining them gain further insight into basic concepts
ot normal and pathophysiology. .'\s a pediatric hcmatologist I perhaps share
in that sort of excitement more than many of my colleagues wlio may see less of
the inlierited diseases. To study a relatively rare disease such as thalassemia
is to learn that part of the hemoglobin molecule is not produced; tliat this
inlierited defect is due to a deficiency of hemoglobin messenger, a cliemical
produced by the liemoglobin gene. In certain tlialassemias tlie hemoglobin gene
is itself missing, perhaps due to some form of abnormal rearrangement of the
chromosomes. Studies of thalassemia tlien led to inquiries into the production
of hemoglobin in tlie fetus and then to development of methods by which the
important inherited hem.oglobin diseases can be revealed in an antenatal diagnostic
teclinique. In another example, one confronts a child overwhelmed by infection
and leanis that the white cells of this child cannot ingest bacteria. By further
study one learns that the child has an abnormal protein in his white cells a
muscle-like protein that cannot function normally and hence one learns that muscle-
cells
like proteins are essential constituents of white. The protein provides the very
muscle of the ingestion process. Thus does the clinician illuminate a basic
process by exaraining patients who lack that process. How does one train clinicians
to make the initial observation and to pursue them? Here the institutional NIH
training programs in medical research, the research career development awards
and special fellowships, are essential. The programs have received severe buffeting
107
in recent years. First they were accused of training too many clinical specialists,
or tlicy were accused of having not trained enough general clinicans. Finally,
they have been accused of training too many investigators for when tl;cre will r.ot
be sufficient opportunities because grants will be depleted. All of these
criticisms are true and untrue. Training programs have not been critically
analyzed, and when they are analyzed the recommendations may be put asiie in
a convulsive effort on the part of the scientific comr.unity and MH adr_:nistrators
programs
to reinstate the' nuickly before they are lost forever. The .-\merican Scciety cf
Hematology lias the resources to study training needs for our field. Sere cf cur
members liave as individuals previously provided such data for Nil; and I-jTv
officials, and we stand ready to do that task again. U'e must train new young
clinicans and investigators. We hope to work closely with Federal officials
to plan appropriate training goals.
3. Peer review . The MericKn Society of Hematology' finds it difficult to consider
methods by wliich Nil! can properly allocate its funds ivithout the use of peer
review. A small band of experts based at NIH is far too limited to consider
the needs of hematolog)-. llie field is enormous in its scope. Practically
every sort of research experience would be needed to rake decisions abcut
hematology grants. Even a Hematology Study Section chosen as a group cf experts
from throughout tlie countr>' and representing almost ever)' field occasicr.ally finds
itself short of individuals who can make the right decisions and must c.-.ll in
outside experts. 'I'he peer review system is not perfect. Tlie process of
reviewing takes many members of the scientific community away from their universities,
sometimes for prolonged periods. 'I'lie system is susceptible to tiie charj;e of
cronyism. But anotlier system such as massive grants to institutions rather than
small graiits to individuals would lead to unhealthy power concentrations at the
top and laziness at the bottom. Ihus there appears to be no substitute for
T08
individual grants judged by tlic peer review method.
4. NUl organization , ihe American Society ot Hematology hns felt tor some time
that blood research needs a more defined home in the National Institutes of
Health, the field is so broad and scattered that it lias been dilticult
for NIll officers to mount an effective hematology research program. For the
most part the nation's research hematologists receive their support from the
National Heart and Lung Institute, the National Institute of Arthritis, Metabolic
and Digestive Diseases and the National Cancer Institute. I'Jiose interested in
immunology and immunologic aspects of hematolog)' are supported in part by the
National Institute of AUerg)^ and Infectious Disease. IVith the development of
a Blood n.esources Program and Sickle Cell iVnemia Brancli in the Heart and Lung
Institute, a small staff interested in disorders of the blood has gathered at
that institute. These individuals are capable of organizing an NIH wide
liematology research program. Actually Dr. Robert Ringler has been requested by
former NIH acting director Ronald Lamont-Havers to develop such a pan-institute
program. Partially to meet tliis need the American Society of Hematology has
recommended that tlie name of the National Heart and Lung Institute be clianged
to the National Heart, Lung and Blood Institute so that the efforts of the
Blood Resources Program of that Institute can be recognized in name as well as
in fact. Happily certain Congressional committees have concurred, and we hope
that the name change will take place. However, this is, as this panel knows,
merely a symbol. Certainly the American Society of Hematology does not believe
that all blood research should be the responsibility of the National Heart, Lung
and Blood Institute. Metabolic studies of the blood should be of interest to NIAfDD
and the studies of hematologic malignancy should certainly be within the province
of tlie National Cancer Institute. Tlie point is that these various interests
need coordination. Goals and priorities need to be set. One needs an appropriately
109
staffed administrative office to accomplisli the coordination. We need to be
certain that institutes expressing interest in particular areas in fact have
tlie funds to pursue them. Too often one sees a grant with a liigh priority
sequestered in an institute that lias insufficient funds to pay wliile another
institute would be more than interested and would pay if it were only informed
of the need. We have seen tliis in the present funding crisis of tlic 1976
budget. In late June of tliis year all NIII institutes informed Research Career
Development Award applicants that awards would not be made until clarification
of the 1976 budget was established. But in September certain institutes, sucli
as Heart and Lung, made RCUA awards while other institutes, sucli as NIA'DD, did
not. llenatologists with liigh priorities from study sections were not funded
with RCD,\s because their grants happened to be assigned to one institute, but
were fuiided, perhaps even at lower priorities, if tlieir applications had been
assigned to another institute. This is an unreasonable situation. One cannot
let the present organization of Nil! unwittingly prevent tlie support of excellence.
Certainly the American Society of Hematology does not believe that a radical
change in NIH structure should take place. We liave categorical institutes.
It would be nearly impossible to change them at tliis late date. But we iiBy greatly
benefit from a readjustment of the internal structure of the NIII, keeping the
categorical institutes but creating pan- institute committees that will coordinate
activities in a given field within all the institutes. We suggest that the
responsibility for this function in hematology be taken by the National Heart,
Lung (and hopefully Blood) Institute.
5. Erosion of basic research by targeted programs. It is often charged that
targeted or contract programs erode funds designated for investigator originated
programs. Indeed this certainly can be the case. It is not the case in the
present structure of the blood program in the National Heart and Lung Institute
110
in which 91-o of the budget is designated for individual investigators and only
95 for contracts. Tliis low budget for contracts may, however, be too low. Xl-.ere
are certain areas of investigation in which the fundamental concepts are fairly
well known, but important data need to be collected. This is ideal for the contract
mechanism. For example, wc need to know whether vaccination and/or prophylactic
antibiotics will decrease the incidence of overwlielming sepsis in children witJi
sickle cell anemia. We have the vaccine. U'e liave the antibiotics, and we have
the patients in sickle centers. We need to develop a targeted program to
investigate this therapeutic ap]5roach. Tliis is an ideal subject for a contract,
but only 48-o of approved grants in hematology were payed by the Bleed Resources
Program of tlie National Heart and Lung Institute as op]Xised to 60s of approved
grants payed by Lung. Obviously a much higher priority is needed by a lieratologist
than a pulmonar>' investigator- -at least these days--in the National ileart and
Lung Institute. If the^ Director of the Blood Program in tlie National Heart ar.d
Lung Institute were to fulfill all desii-able contract obligations, even less tha'-.
48°i of approved grants would have been payed. So in the present structure hard
pressed research administrators with insufficient funds to meet all their needs
must make very difficult and perhaps incorrect decisions. y\bove all, the admini-
strators lack flexibility because of the uncertainty of funding fror. year to year.
Obviously this panel cannot correct all of these problems because ti-.e limit on
the system is the federal budget and the amount funnel ing in to the Institutes
in the first place from tlie Congress and the President. Certainly NIH will alwav?
be short of funds if the training programs live up to tlieir promise and produce
bright young people with good ideas in sufficient numbers. To help make decent
decisions, Nlil staff must be of high quality in adequate numbers. A program
administrator cannot possibly take the time to analyze need, listen to advice,
gather new data and talk to his peers if he also answers liis phone and t>'pes
his own letters. In tiie minds of some, NIIl is considered as some sort of over-
blown bureaucracy. But this is simply not true. There are today many de\oted
111
and intelligent administrative and scientific public servants at NIII working
for far less compensation tlian do their university counterparts. In fact this
is becoming an extremely serious problem for the universities as well as MIH.
A decade ago NIH was the spawning ground of nearly every bright young investigator
in the medical sciences in the United States. IXie to the abolition of the draft
and the failure to keep senior personnel because of salary restrictions, tJie NUI
is becoming less attractive as a training program. Tliis may well have adverse
effects upon future generations of trainees. Strong support of the internal
research program of NIH as well as the staff of the extramural programs should be
urged by this panel . • \ .
Finally, the ^Xmerican Society of Hematology believes that the panel should
take the opportunity to investigate the Nil! in as broad a fashion as possible.
It lias been charged in some quarters that the advancing NIll budget has somehow
adversely affected primhry medical care in tlie United States by providing a
funding source that diverts individuals wlio would liave become primary physicians
into research or specialty careers. It is extremely liard to find data that
seriously address tliis question. True, NIH has provided funds that have developed
research in medicine and the researchers themselves liave tended to be specialists.
But increasing opportunities for specialists came about only because medical
schools and teaching hopsitals proliferated, lliis proliferation resulted in
the training of more medical students most of v.iiom l)ecame primary physicians.
In any case, tlie .American Society oi Hematology believes that we sliould once and
for all attempt to analyze how research affects the United States positively and
negatively; that we should try to put aside ill considered paneg)'rics that either
place researcti m sacred cow status or beat it mercilessly because it is a
convenient scapegoat for our general failure to develop a reasonable national
medical plan.
112
In conclusion, the American Society of Ilematoiofv stands ready to assist
this panel in any way it can for we believe in your mission and will place our
resources at your disposal.
Tliank you.
113
OR OS^AR O RATNOFF
Cli-v-i.r-j. O^.D MlOfi
ORG LO(''<AHOCONLEV
American Soc\et\i of Hematology
DR. SAMUEL
Vvte'-it Aijminiitradon HofpiUI
33^0 La Jolla Villag* Dfiv«
SaiOie90.C.Ho.n>a 92161
OR THOMAS B. BRADCEV
V A Moipital (ISIA)
4150 Clement Strttt
San Franoico, CaKtnnui 94 1 21
TrtMum,
OR. ALVINMAUER
SI >K(« Ch.ldron'j RiMarch Hoip
337 Nwth Lau*fd»l«
UMTvhii. TenntUM 38101
DR. THOMAS HALE HAM
Dartmoulh School of M«<Jicin«
H3r>over. Nfw Hflrnpshirt 03755
CouiKil/on
DR. ELMER 8. BROWN
Waih.njion Un.,«f,.tv
School o' Medic.h*
Si Lo.iit.MisJoof. 63110
DR. BERNARD A. COOPER
Roval Victoria Howttl
h^omreal. 1 1 2. Qutbec. Canada
DR. ROBERT F. SCHILLING
Madijon. Wisconsin 53706
DR RALPH O. WALLERSTE1N
3a3S Cahlornia Streat
San Francisco. California 941 ia
September 10, 1975
Charles U. Lowe, M.D.
Executive Director
President's Biomedical Research Panel
Z^tOl E Street, N.W.
Suite 3100
Washington, D. C. 20037
Dear Doctor Lowe:
On behalf of t
express to the Pres
on three current is
the academic resear
of hematology in pa
request the opportu
Hospital in Boston
The issues we wish
of support for basi
Insti tutes of Heal t
tinuing support for
Insti tutes of Heal t
Inst I tutes of Heal t
he American Society of
ident's Biomedical Res
sues that we believe a
ch community as a whol
rticular. I have writ
nity for Dr. David Nat
to testify on our beha
to address are : ( 1 ) t
c biomedical research
h, (2) the need for an
training in research
h, and (3) the organiz
h (NIH) .
Hematology, I wish to
earch Panel our views
re important both to
e and to the discipline
ten to Or . Lout i t to
han of the Children's
If before the Panel,
he role and importance
by the National
d importance of con-
by the National
ation of the National
OR IRWIN M. WEINSTEIN
465 N RoKburv Driva
Bflvar iv Hills. California 90210
DR HELEN M. RANNEY. CHAIRPCRSON
PO Bo« 109, BSB
Uniwarsitv of California at San Oisgo
U Joila. California 92037
DR GEORGE 6RECHER
San Francisco Medical Canlsr
Sar. Francisco. California 94143
DR. GEORGE CARTWRtOHT
OR
EUGENE CRONKITE
Br0<
iVha.an National Laboraloriai
Upli
an. L 1 .N«« York 11973
OR
FRANK GARDNER
Pres
Oyrsrian.Univars.ty ol
Pe
n^sylvania Madicsl Center
Ph.l,
Jdolphia. Pennsvlvania 19104
OR.
WALLACE JENSEN
G^
'^' Washington Un,.,„it,
vv."i
l.ngton. DC 20037
DR
JOHN LASZLO
Ovk
( Medical Center
Dj.i
lam. North Carolina 27710
DH
J F. MUSTARD
Basic Biomedical Research
The American Society of Hematology believes strongly that
support for basic medical research by the NIH has been respon-
sible for a succession of many significant advances in our
understanding of the biology of disease and the practical applica-
tion of this knowledge for the care of patients. This research
has disclosed areas of knowledge, moreover, that provide con-
siderable hope for future pragmatic advances. We believe this
type of support must be continued by the NIH if we are to continue
our attempts to uncover new modes of diagnosis, prevention and
therapy. The impact of past support and insight into the present
benefits and possible future benefits to be derived from basic
biomedical research supported by the NIH was summarized excel-
lently in testimony before the House Subcommittee on Public
Health and Environment, presented recently by Dr. Maxwell
Wintrobe. A copy of Dr. Wintrobe's testimony is enclosed for
your interest.
1975 Annual Ma«ting: Decemb«r 5-10 Thfl Fairmont Hotel Dallas, Texas
Business Office: Charles B. Slack. Inc.. 6900 Grove Road, Thorofare, N.J. 08086 1609) 848-1000
115
Charles U. Lowe, M.D.
September 10, 1975
Page Two
Research Training Programs
We feel equally strongly about the critical importance of continuing
NiH support for research training programs. Clearly, our potential for the
continuation of the medical research that has brought us to our present
state of understanding requires a steady influx of properly trained young
men and women. In time, they must assume the vital task of continuing
medical research programs already in progress and of providing those new
ideas and new approaches that will insure future progress. A study conducted
by Dr. Helen Ranney, immediate past President of the Society, published in
B 1 ood , Volume ^0, pages S7^-5^^, 1972, demonstrated that a large proportion
of available academic positions in this discipline remains unfilled, and
we believe the situation remains unchanged. Thus, the academic community
recognizes the continuing need for training programs for potential investi-
gators in this field, and we urge support for efforts in this direction.
Organization of the National Institutes of Health
The American Society of Hematology does not feel that major organiza-
tional changes within the National Institutes of Health are currently
needed. The question of organization has been a recent matter of concern
to us because, as documented on the enclosed table, from data collected
by Dr. Ernest Simon, Director of the Division of Blood Diseases and Blood
Resources in the National Heart and Lung Institute, support for research
and research training in blood diseases and blood resources is scattered
throughout nine Institutes and the Division of Research Resources within
the NIH. This situation reflects the impact of hematologic research upon
many disciplines, and has been a healthy phenomenon, providing cross-
fertilization of thinking among investigators of diverse interests.
Rather than compelling a reorganization of the NIH, this broad support
suggests the need to establish meaningful ways of providing communication
about priorities and funding among the various institutes supporting a
given special area of interest. In January of 1975, at the direction of the
Executive Committee of the American Society of Hematology, our Public
Information Committee met with Dr. Lamont-Havers , then Acting Director of
the National Institutes of Health, to urge communication and coordination
among the Institutes. Thereafter, Dr. Lamont-Havers designated Dr. Ringler,
then Acting Director of the National Heart and Lung Institute, to coordinate
activities involving research and research training in blood diseases and
blood resources throughout the NIH. In our opinion, this type of communica-
tion and coordination is distinctly preferable to any general overhaul
in the NIH structure.
Another facet of great concern to our Society is the peer review
system for determining the merits of applications for support of research
and training programs. Recognizing that inequities may creep in, we
nonetheless believe that peer review has provided fair and disinterested
method with less bias than any other proposed system and we urge its
continued use.
116
Charles U. Lowe, M.D.
September 10, 1975
Page Three
We appreciate the invitation extended to the Society to express
its opinion on these matters extended in your letter of April 8, 1975
to our Secretary, Dr. Thomas B. Bradley. As I have noted, we would appreciate
the opportunity for Dr. Nathan to appear before your Panel to amplify
or clarify any of the opinions that 1 have expressed.
Oscar D. Ratnoff, M.D.
President
ODi^;
; jwn
End
losures
cc:
Mr.
Beno C.
Schmidt
Drs,
, Robert
H. Ebert
Albert
L. Lehninger
Paul A
. Marks
David
Skinner
Ewald '
tfl. Busse
C. Loc
kard Con ley
Samuel
Rapaport
David
Nathan
Thomas
Bradley
Robert
1. Weed
117
Enclosure 1
TESTIMONY BEFORE THE SUBCOMMITTEE ON PUBLIC HEALTH AND ENVIRONMENT, U.S. HOUSE
OF REPRESENTATIVES REGARDING THE RENEWAL OF THE HEART, BLOOD VESSEL, LUNG, AND
BLOOD ACT OF 1972
by
MAXWELL M. WINTROBE, M.D. , PH.D., PAST PRESIDENT, AMERICAN SOCIETY OF HEMATOLOGY
VICE PRESIDENT, INTERNATIONAL SOCIETY OF HEMATOLOGY, MEMBER, NATIONAL ACADEMY
OF SCIENCES
Because this is the first time that representatives of the American
Society of Hematology have appeared before Congress I would like to make a
brief statement regarding the scope of the term hematology; the nature and
results of research in this field; how such research has enlarged our under-
standing of life processes; to what extent we have been successful in relieving
or easing the ills of mankind; and what tasks lie before us.
Hematology includes fundamental studies of the blood itself and of the
diseases thereof. It encompasses the fluid or plasma in which the blood cells
are carried as well as the red and white blood cells and the platelets; the
bone marrow where the blood cells are made; and the spleen and lymph glands.
The term blood resources refers to products derived from blood that are used
in treatment.
Mankind has always been interested in the blood. The blood nourishes all
the tissues of the body. Without it, life is impossible. Because it is so
readily available, blood has been the subject of study longer, perhaps, than
any other tissue of the body and this has brought untold benefit for mankind.
Since the early twenties research in hematology has been very productive; par-
ticularly is this true of the past 25 years. We are now in the midst of a
veritable explosion of understanding of the disease processes which are
classified as blood disorders. Regrettably, there is real danger that these
promising advances will be brought to a halt as a result of reduction in the
financial support which has made these discoveries possible.
119
In the chart I have placed before you I have indicated a few of the
areas in which research conducted within the past 50 years or so has
progressed most gratifyingly and I have indicated what the fruits thereof
have been. You will note that the advances that have been made are of
a widely varied character. I shall try to point out also how the pursuit
of knowledge brings unforeseen rewards. Research, if done carefully and
imaginatively, yields benefits which often are unforeseen at the time it
is being initiated.
Let me cite a few examples. In 1926 the successful treatment of
pernicious anemia with liver was announced. This was the result of a
search for the food substances which are needed for the manufacture of
red blood cells. For the victims of pernicious anemia the discovery of
the effectiveness of liver therapy meant long, happy life instead of
certain death, usually within a year or two. But this was only a small
part of the dividend. Research into the ways in which certain food factors
affect blood formation also led to the discovery of folic acid. This was
followed by the observation that children with acute leukemia became
worse if they were treated with folic acid. This in turn led to the
production of compounds antagonistic in their action to folic acid,
substances which interfere with the growth of cells. With the development
of such folic acid antagonists, and also as an outgrowth of the study of
the effects of mustard gas during World War II, modern chemotherapy was
born. Chemotherapy means the treatment of disease, particularly various
forms of cancer, with drugs which interfere with the growth of cells. And
it is not only blood cell cancers which are attacked by these agents.
Chemotherapy now is being employed in the treatment of so-called solid tumors
breast, bone, bowel, etc.
120
Another outgrowth of the original studies directed toward the under-
standing and treatment of pernicious anemia was appreciation of the fact
that the growth of cells depends not only on their being supplied with
protein, vitamins and minerals. We came to realize that there are mechanisms
within the body which control cell growth. The study of such controlling
mechanisms has led to a better understanding of genetics, including human
genetics - that is, how the implantation of a sperm within an egg results
in the development of a human being - how this is controlled and how the
mechanism can go wrong. Thus, we have learned how one of the polypeptide
chains which make up the hemoglobin that carries oxygen to our tissues,
when not correctly constructed, results in such diseases as sickle cell
anemia and Cooley's anemia. From such an understanding investigators now
are seeking ways whereby a disordered mechanism may be set straight. We
are not quite there yet, but we are close!
Let us take another area - blood transfusion. The four blood groups,
A, B, AB and 0, were discovered by Landsteiner in 1901, This made blood
transfusion possible. But reactions occurred. Women who had previously
been transfused or had received injections of certain blood products
began to give birth to dead babies — or, if the babies were born alive,
there might be severe brain injury. Then came the discovery of the Rh
factors - then exchange transfusion as a form of treatment — and now
methods have been developed whereby Rh disease can be prevented, thereby
eliminating what was once a serious hazard for couples whose bloods were
incompatible.
There have been many other dividends resulting from the original research
related to blood groups and blood transfusion. Cardiac surgery would be
J21
impossible today if methods for the collection and storage of blood had not
been greatly improved, blood banks developed and all the factors that are
involved in reactions to transfusion investigated. And I should add that
all that you have heard about transplantation of organs would still be
impossible if we had not learned about the ways in which the body reacts
to foreign tissues and how these may be controlled. Such information had
its roots in the search for a way to transfuse blood without causing adverse
reactions.
I can only mention the process of coagulation, the clotting of blood.
We are beginning to understand the detailed steps involved in this very
intricate mechanism. This has made possible an increasingly successful
attack on bleeding disorders such as hemophilia. What was once a dread
disease which brought both physical and financial crippling to male members
of certain families, by methods of treatment arising out of identification
of factors involved in the clotting of blood, the victims of hemophilia can
now look forward to an essentially normal future. On the other hand, in
regard to the clotting disorders, thrombosis - the process which leads to
obstruction of the circulation of the heart and of the brain, resulting in
heart attacks and stroke - we have yet a long way to go.
When one reviews the long list of accomplishments to date, of which
I mention only a few, when one takes the time to understand how research
has resulted in so enormous a growth in our knowledge and understanding, when
one sees the resulting benefits in the welfare and happiness of mankind, it
is difficult to believe that anyone responsible for the welfare of the people
of this country can consider cutting back on the funding of research and
122
research training. You are well aware, I am sure, that in spite of all the
extraordinary gains made to date, there is much left to learn before we
achieve our objective of conquering and preventing the diseases which
plague mankind. I can only explain the desire to cut back on funding
to a lack of understanding of the issues involved.
Excellent opportunities lie before us if we fund our research
programs properly, and if we improve the organization and authorities
of the major institute supporting that research, the National Heart and
Lung Institute. Dr. Helen Ranney will give the reasons why we have
proposed amendments concerning the organization and authorities of that
Institute. I will close my remarks by commenting on the levels of funding
that will be authorized by this bill. We are all aware that the Adminis-
tration proposes to cut back on the authorized levels for this legislation
and in another action, are cutting back substantially on appropriations for
the field.
In relation to the total amount of money which our government spends,
that provided for medical research is a very small proportion. I would
stress that the return on every dollar supplied has proportionately been
far greater than the dividends which come from expenditures in any other
area. In closing I wish to emphasize three points:
(1) Hematological research, because of its inherent breadth, has not
only led to greater understanding and treatment of blood diseases;
it has also contributed and continues to contribute to cancer
therapy, surgery of all kinds, cardiovascular and pulmonary disease,
nutrition and other areas.
123
(2) Funds used for the support of fundamental research - research which
leads to understanding of the nature and causes of diseases - in the
end yield greater dividends than funds used in the treatment and care
of the victims of disease. Admittedly the latter are needed but a
proper balance in the distribution of funds for these respective
purposes is essential.
(3) Research requires people - investigators who have ability as well as
imagination; people who have been trained, men and women who will
carry on in the future. During the golden days of the National Insti-
tutes of Health research support program an atmosphere was created
which attracted to medical research a small but sufficient fraction of
promising medical students. They were attracted because they were led
to believe that if they worked hard, secured good training and were
imaginative, the future lay before them. This is what led to the
great advances we have seen in the past 25 years.
Unfortunately, the atmosphere has been changed. Already we are seeing
the ill effects of the cuts in the support of research and research training
which have been made in the last few years. No longer are there many
promising young people coming into the field. They have been discouraged
and they are being forced to seek other occupations. This is an extremely
serious matter which is not easily nor quickly corrected. We cannot start
too soon to turn the tide. Our future and that of our children is being
compromised by the short-sightedness which has marked the last few years.
124
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125
Enclosure 2
PROFILE OF HEMATOLOGY SUPPORTED AT NIH
Table 1
Total Fxtrainural Blood Research at NIH FY V-T
Institute
Amount (mil 1 ion>)
Allergy (tllAIO)
*6.4
Arthritis (J1IA!30)
9.5
Cancer (t.'CI)
♦14.04
Child I'e.ilth (niCHO)
"■ ' 0.97
Dental (;JiC.H)
0.35
Environ-ental Health (tilEHS)
*0.6
Eye (r;El}
0.07
General "edicine (MGKS)
1.41
Heart (l;:-iL!)
51. C
Neurology (riluDS)
0.0
Research Resources (ORR)
*5.0
Total
*89.35
*fjgures are approxif.ate.
Table 2
Extra^n-jral Support of Herriatology Program Areas at the MIH (FY '74)*
tllAID
HIAMDD
MCI
KIGMS
NICHD
NHL I
1.
Blood Cell Forrjticr., Function, and Kinetics
2
1
2
2.
H.er-oglobins: Synthesis, Structure, Function
2
1
2
3.
Red Blood Cell Transport and Ketabolism
1
1
2
4.
Hypoplastic Aner.ias
2
3
1
5.
Iron Transport and Ilstabolism
*■
6.
Deficiency Ane:;iias
4
1
7.
Hemolytic Anenias
1
4
8.
Blood Coagulation
4
9.
Leuke.Tiia a;.d Frythroleukemia
4
10.
Tii-ors of the Hematopoietic Systcni
4
11.
Plas-3 Cell Disorders and Dysproteinerias
?
1
4
12.
Clood Crojpinrj, Transfusion, Safety of
Bleed Tlierapy (including Hepatitis), Blood
Cosg. Therapy, Cone Harrow Transplantation
2
3
13.
OtI.cr
4
Total (riillions)
6.4*
9.5
14*
1.4
1.0
51
% Support of Prorirani A rea
1 = V0-T0l~3 = 50-'V'S;,
2 = 25-52;. 4 = 75-lCO:;
127
AMERICAN SOCIETY FOR MICROBIOLOGY
1913 I Street, N.W.
Washington, D. C. 20006
Telephone: Code 202. 833-9680
This Is a statement prepared by the Public Affairs Committee of the American
Society for Microbiology and presented by Harlyn 0. Halvorson, Ph. D. , Vice-
President of the American Society for Microbiology, member of the Public Af-
fairs Committee, and Director, Rosenstiel Basic Medical Sciences Research
Center, Brandeis University, Waltham, Massachusetts.
The objectives of the American Society for Microbiology, encompassing a member-
ship of over 23,000, are to promote scientific knowledge of microbiology and
related subjects through discussions, reports, and publications; to stimulate
scientific investigations and their applications; to plan, organize, and ad-
minister projects for the advancement of knowledge in this field; to improve
education in the science; to promote programs of professional recognition;
and to foster the highest prof essiona]. and ethical standing of microbiologists.
The science of microbiology grew out of an expanding interest in fields re-
lated to bacteriology. Bacteriology, i^irology, mycology, biophysics, biochem-
istry, and others are all included in the larger field of microbiology, re-
flecting evolving concern with virus<;s, fungi, and subcellular processes.
Many disciplines have become more microbiologically oriented, leading to some-
what of a fusion of disciplines - microbial genetics is an example.
A foundation in microbiology is basic to the understanding of numerous health
issues. The Society's membership includes microbiologists who are recognized
experts on a given health-related topic, and can provide answers to questions
that legislators raise in order to make intelligent decisions on bills presented
129
to them. Because microbiologists know their subject in depth and in its his-
torical context, they can view issues in perspective. They can commenL on the
rationale behind, and implications of, legislation in addition to furnishing
information.
We strongly feel the need to strengthen the classical basic medical science
disciplines, including microbiology. While we recognize the need for funds for
targeted research and training areas dictated by societal needs, we feel that
these needs should not exclude adequate support for the classical, basic med-
ical science disciplines. It is our f«:eling that the recent trend toward
categorical or targeted research has perhaps unintentionally deemphasized the
need for training in classical disciplines such as microbiology. Solutions to
current problems in health, energy, agriculture, and the environment all require
basic information in disciplines such as microbiology. We are all aware of the
lack of documentation of good manpower needs data. In this connection, the
American Society for Microbiology plans to conduct a comprehensive manpower
survey related to the current supply and the future needs for microbiology.
Consultations have already taken place with the Administrator of the Health
Resources Administration and with officialsof the National Academy of Sciences.
It is nevertheless our conviction that there are a number of areas for which
openings are available, and training necessary in the field of microbiology.
For example, pending health legislation will likely create an even greater
need for board-certified microbiologists at the postdoctoral level in clinical
and -medical microbiology than now exists; however, no training funds are avail-
able in this critical area. Again, in the absence of documented manpower needs,
most of us are aware that clinical and medical microbiologists are still in
demand at this time. However, we should not increase training funds in the area
of microbiology at the expense of research funding in microbiology as it
130
applies to infectious disease, and other targetable needs.
One of the reasons that past funds for training and research in microbiology
have been so effective is that they have been subject to rather thorough peer
review processes. Although no process for the determination of merit of any
proposal is perfect, V7e strongly feel that the peer review system is essential
for the judicious expenditure of public funds for both training and research
in microbiology. It is important to emphasize that we are speaking of the peer
review process for the establishment of scientific merit of both grant and con-
tract proposals, and perhaps the degree of relevance to a targetable program
which has been identified by some other advisory process and obviously is
under the ultimate control of Congress.
Events over the past five years lead us to believe that there is a great need
for more long-term financial and leadership stability at NIH, and especially
at the Directorship level. Such long-term stability within NIH, in our opinion,
will depend to a great extent on a finite term for the Director, and we would
suggest a period of from three to five years. We would prefer a finite term
of four years, subject to reappointment. It seems reasonable to expect that
a period of two to three years would be required for any Director to comprehend
the complexities of NIH, and his/her services should not necessarily terminate
a year or so afterwards. We also feelthat the Director should be appointed
after thorough search by an appropriate internal advisory committee.
The field of microbiology, as one of the biomedical sciences, has been weakly
represented, if at all, in the past in councils advisory to the Executive Branch.
Considering the importance of microbiology and immunology within the biomedical
sciences as they pertain to the public health, we strongly feelthe need for
better scientific advice in these areiis at the executive level. Our thinking
leads us to suggest for consideration that the President's Biomedical Research
131
Panel might be made a permanent advisory panel at the executive level, or that
it function in some form as a subcommittee, or a subpanel, of any future PSAC.
As Vice-President of the American Society for Microbiology, and on behalf of
the Public Affairs Comittee of the Society, I want to thank you for the oppor-
tunity of presenting these views, and I would like to assure you that the
Society stands ready to be of any assistance whatsoever in your future deliber-
ations.
132
COUNCIL OF THE AMERICAN ASSOCIATION OF CHAIRMEN
OF DEPARTMENTS OF PSYCHIATRY
PSYCHIATRIC RESEARCH:
CURRENT STATUS AND RECOMMENDATIONS FOR THE FUTURE*
We are cognizant of the broad range of issues the Panel must
consider in its review of biomedical and behavioral research. We are
aware also of the testimony given by the Council of Deans of the AAMC
and the Professors of Departments of Internal Medicine. Here, while
we will make some similar recommendations, we shall emphasize particularly
the special opportunities, problems and needs relevant to research into
mental illness and behavior, including the role of ADAMHA in this research
effort. Many scientists, including those from psychology, sociology,
neuropharmacology, neurochemistry and anthropology contriiaute to research
related to mental health and illness. We shall speak particularly,
however, from the point of view of the profession of psychiatry and
especially the academic departments of psychiatry (which include many
such cognate scientists), for we firmly believe that it is in this
unique setting that research relevant to mental illness can be pursued
optimally.
Being a physician, the major professional focus of the psychiatrist
is the maintenance of health and the alleviation of disease. Hence,
psychiatric research seekr to define the pathology of the mental disorders,
to understand their genesis, and to identify the relative importance in
that genesis of social, psychological and biological variables. Through
an understanding of these factors, it attempts to continually update
methods of prevention, treatment and eventual eradication of mental illness.
These objectives differ little, if at all, from those of other areas of
biomedical research.
Again, in keeping with many other areas of biomedical research, the
past two decades have witnessed exciting new developments in psychiatric
research with associated strides being made in our understanding and
treatment of mental illness.
On close inspection, however, it is important to note that strength
in some areas of the research effort has developed only recently. This is
particularly true in clinical psychiatric research where only now are we
approaching a cadre of experienced investigators. Furthermore, over the
past five to six years, possibly as a result of the rapid growth of service
and social program responsibility of ADAMHA, federal support for the research
effort has faltered and seriously endangered the total enterprise. We
address several of ttiese issues in the discussion which follows,
* A statement prepared for the President's Biomedical Research Panel by
members of the Council of the American Association of Chairmen of Departments
of Psychiatry (AACDP). The AACDP represents all the academic departments of
psychiatry within the medical schools of the United States.
133
Special Factors to be Considered when Reviewing Psychiatric Research Effort
A tradition of research and research training in psychiatry has only
recently been established. Whereas the Rockefeller grants to medical
schools in the 1930's enhanced the clinical research base of general
medicine, it was not until the 1950's that comparable developments occurred
in psychiatry. Some schools and individuals stand out in their early
vigilant efforts to develop a research base, but these were a lonely few.
It has been estimated for example, that in the late 1940's there were
no more than 20 psychiatrists in full-time psychiatric research in the
nation as a whole. The cadre of senior scientists so essential in the
generation of a solid sequence of young investigators is only now becoming
established for psychiatry.
Several factors have contributed to this delay:
1) The variables to be considered in an understanding of mental
illness are typically broader than in traditional biomedical research.
While the management of all disease demands an awareness of social and
behavioral, as well as biological perspectives, it is especially true in
psychiatry that social and behavioral components have been vitally relevant.
An integration of these different variables, each with their own appropriate
methodology, has been difficult to achieve. Collaboration with colleagues
outside the traditional biological and medical disciplines has been
essential bu' is not easily focused upon the disease entity.
2} In contrast with internal medicine, it is only in very recent
years that the research methodology and body of knowledge available in the
basic sciences pertinent to psychiatry have achieved a sophistication
sufficient to allow their application to an understanding of psychopathology.
3) Psychiatric patients occupy approximately every other bed in
American hospitals. The need to provide care for these individuals, frequentl
with inadequate numbers of trained professionals, has generated a pressure
to develop and utilize empirically-based treatments and social programs.
Scientific inquiry regarding these methods has frequently been forced into
the background or seen as irrelevant by overworked practitioners.
4) Associated with the above situation, the public understanding of
psychiatry has generally been equated with the "snake-pit" image, or the
"plush avenue couchmen", rather than with the leading edge of scientific
and academic effort within the discipline. Hence, there has been in
contrast to such areas as cancer and cardiovascular disease, a lack of
consistent public pressure for sustained scientific investigation into
the roots of mental illness.
13^
Brief Historical Background of Psychiatric Research
As noted earlier, before the end of World War II, academic departments
of psychiatry existed in only a small number of American medical schools.
The majority of the mentally ill were cared for outside these centers, in
state hospitals, in private hospitals, in sanatoria, and in the offices of
a small number of private practitioners. The war experience, however,
brought to the attention of society at large the extent and morbidity of
mental dysfunction. The number of Americans classified as unfit for
military service for neuropsychiatric reasons was over 1.8 million, or
well over 10% of all registrants examined. Of the men who passed the
screening and went on into military service, about one million (almost
10%) were hospitalized for neuropsychiatric reasons, and some 500,000
received psychiatric discharges. Clearly, psychiatric dysfunction was a
far more widespread problem that had ever been recognized before.
This awareness, together with the energy and vision of a small group
of individuals, led to the creation of the National Institute of Mental
Health. Unlike the other institutes of health, the NIMH had from the
beginning a mandate not only for research, but for the development of
training programs for clinical psychiatrists and the building of model
service programs as well.
Direct financial assistance from the newly-established NIMH permitted
the expansion of existing academic departments of psychiatry and the
development of new ones within the medical schools. These departments grew
to become involved in the care of individuals tliroughO'.-t the medical center,
and developed responsibility for hospital-based services of their own.
Psychiatry assumed increasing teaching responsibility in both the pre-
clinical and clinical years of medical student education.
However, at the same time as this academic base for psychiatry was
being developed, the awareness of a need for a radical change in the
approach to the treatment of the mentally ill was also being felt. Mental
illness has always been a quasi-public responsibility and the development
of a capacity to provide psychiatric services within the general medical
center hastened the trend towards a community-based treatment of the
mentally ill. The movement culminated in the Kennedy Act, and by the mid-
1960's the National Institute of Mental Health was spearheading a new public
health approach to mental illness - the commimity mental health movement.
Vital as this movement has been, its effect upon psychiatric research has
been unfortunate and far-reaching. Not only has it diverted attention
from the effort, but also fiscal support, so that now there is, between
service and research, conflict rather than complement. We shall return to
this point later and in our recommendations.
35
The generation of a sequence of competent clinical investigators
was just beginning to promise a stable base for psychiatric research,
when the uncertainties and cutbacks of research and research training
intervened in the late 1960's. During the previous decade, clinically
competent investigators and basic scientists at the NIMH campus had
been developing methods and prototypes for investigating the etiology
of mental dysfunction and a genuine bio-behavioral expertise had begun
to emerge in various medical centers and some interested psychology
departments. The research career development programs, which began in
1954 at NIMH, have played a major role in the development of extramural
expertise. Indeed, it has been so successful that it is difficult to
rationally explain the Administration's persistent efforts to discontinue
itl Of the 68 M.D.'s completing five years of the av/ard between 1960 and
1973, 67 were still in research, academic psychiatry or public
administration by the end of that period. The data show that for the whole
program, since its inception, only three M.D. scientists have left
research to enter private practice. Furthermore, the program has exemplified
the effort to integrate all relevant disciplines into the research base.
In 1972, it was estimated that there were approximately 250 full-time
mental health research scientists in the United States, of whom about 200
were either directly supported by the research development program, or had
been introduced to research through that program. NIMH statistics
gathered in July, 1972 show that approximately 60% of the awardees were
sponsored by medical school departments, and of these 7R% were in
departments of psychiatry. Of those working outside medical schools, more
than half were in departments of psychology.*
Brief Overview of Recent Advance in Psychiatric Research
Our understanding of mental illness and behavior has increased
enormously over the past two decades, particularly in the area of the basic
biological processes which are associated with behavioral dysfunction.
Major pharmacotherapeutic discoveries were made in the mid-1950' s, and
.•during the same period neurochemistry began a rapid advance. Genetic
studies have begun to clarify the role of biological predisposition in the
development of the major psychoses, and together with biochemical studies
offer for the first time the possibility of a classification of mental
illness, based both on behavioral and biological parameters. The opportunity
subsequently arises for the development of a more precise and rational
approach to therapy. Biochemical, physiological and behavioral markers may
help, for example, in identifying individuals at risk for a specific
dysfunction or maladaptive response. Such advance would provide for the
first time a tangible base for preventive psychiatry.
Booth, B.E., Rosenfeld, A.H., Walker, E.L.; History of the Research
Development Program; in. Toward a Science of Psychiatry , page 143.
Brooks-Cole Publishing Company, California 1974.
136
In severe depression ( melancholia ) , for example, a dysfunction which
is estimated to afflict 10% of the population at some point in a lifetime,
genetic, familial and biochemical studies have brought us to the threshold
of a new clinical knowledge. New efforts at classification, diagnosis,
follow-up and epidemiology are now demanded, if we are to move to a
rational cataloguing of effective treatment. Advances in psychoneuroendocrinology
and the biochemistry of the central nervous system go hand-in-hand with
advances in our capacity to intervene psychopharmacologically, and to
shorten the period of illness from months to weeks. In manic depressive
psychosis, we are now able to prevent future recurrence in 80% of cases.
In schizophrenia , detailed studies of twins, of adoptees and adopting
families have been important in clarifying the genetic predisposition to
the illness in certain individuals. These major research advances have set
the stage for a detailed investigation of potential biological dysfunction
(e.g., in the dopamine system) in schizophrenia, and the interaction of
those biological factors with pathogenic mechanisms of family communication.
Effective drugs have been developed to control many of the major symptoms
of schizophrenia, but more intensive investigation is needed to specify
the concomitant neurobiological defect so that specific psychopharmacologic
intervention becomes possible. Further, we must probe the interaction of
social support and drug therapy in the maintenance of individuals with
schizophrenic disorder in the community.
Child development research has broadened to become an exciting
discipline. Observation of the results of separation in young children and
in primates has built an understanding of bonding, attachment and loss.
These new insights have influenced child-rearing practice and provided a
conceptual base for the development of models of psychiatric dysfunction
in later 1 ife.
Sleep research has provided for the first time a rational approach
to insomnia. It was estimated in 1967 that $70 million was spent by the
public of the United States for hypnotics and sedatives. In 1973, five
million prescriptions were written for Seconal alone. Since the mid-1950's
psychiatrists have joined with other scientists in the study of sleep.
A combination of neurophysiological , biochemical and behavioral techniques
have clarified the nature of disturbed sleep in a variety of mental disorders
and its response to behavioral intervention and pharmacotherapy. Sleep
clinics have been established based upon this new understanding, and the
rational approach to the treatment of insomnia is developing.
Even this brief overview of developments indicates that more research
support than is presently available is needed and will bear fruit in such
areas as: 1) clinical psychiatric investigation directed at broadening our
understanding of the pathophysiology of schizophrenia, the affective
disorders and psychopathy (as it relates to substance abuse); 2) longitudinal
studies of the natural history of these disorders and studies of outcome of
137
the disabilities as they are modified by current therapeutic approaches,
3) the development of mechanisms of assembling an accurate data base from
which epidemiological description of these major mental dysfunctions can
be built; 4) a strengthening of the present effort in basic and clinical
psychopharmacology and toxicology. In this latter area, particularly vital
is a study of the long-term effects of the psychoactive drugs; 5) improved
service delivery research based on well-conceived pilot projects prior to
the investment of major, on-going support for service programs.
It is the ultimate irony that just when the efforts of the past 15
to 20 years to establish a research base in psychiatry begin to bear fruit,
there is clear evidence that support for the effort has begun to plateau
and falter. Studies such as those outlined above will not be possible
without available manpower. The major reduction in research training could
deal a crippling blow to what is only just becoming a viable manpower base.
Probably another fifteen years of sound and vigorous support is necessary
for the manpower pool in the mental health sciences to become a "natural"
part of the health research manpower resource.
But why has the bureaucratic commitment to mental health research
and research training faltered at a time when rapid advance in knowledge
is evident, and there is growing excitement in the field to pursue leads
developed? Certainly one simple explanation is to cite the cutback of
federal research spending in general - and yet, as we shall see later
mental health is the only major research budget which has truly declined
since the la-^e 1960's. This is obviously not the total explanation. Some
of the difficulty seems to lie in the increased demands placed upon NIMH
and later ADAMHA to administer major service programs and the associated
constant, and sometimes frenetic shuffling of the administrative structure.
The Birth of ADAMHA: A Decade of Organization and Reorganization
A recent NIMH Task Force* describes the background of the reorganization
«f the NIMH as follows:
"From 1964 to 1958 the growth of research support
diminished, but the responsibilities of the Institute
as a whole increased and its organizational structure
became more complex. NIMH was in a state of almost
continual organizational flux. Its internal structure
was re-shaped and its position within the Public
Health Service was changed twice in three years.
"The most extensive reorganization of NIMH occurred
during 1966. The addition of the community mental
health centers program had so increased NIMH's
responsibilities and budget that changes were
required both within the Institute and in the Institute's
relations with other agencies. The Department of
Health, Education and Welfare gave NIMH independent
* Resfearch in the Service of Mental Health ; U.S. Government Printing Office,
Washington, D.C., 1975.
138
bureau status in the Public Health Service. This
change, which was formally made on January 1, 1967
helped precipitate a re-examination of the Institute's
internal structure.
Internal change was also influenced by the changing
social climate. This was the era of the Great
Society's attack on poverty, crime, urban problems,
drug addiction and alcoholism. President Johnson
had pledged to apply scientific research to some of
the nation's social ills. NIMH had supported research
and demonstration projects on the mental health aspects
of numerous social problems and now it- was encouraged
to sharpen its focus by creating special units, or
centers, to deal with such problems.
... Centers were established to coordinate research
training, demonstration, consultation and communication
efforts in nine areas: alcoholism, drug abuse, crime
and delinquency, the mental health of children and
youth, suicide prevention, schizophrenia, mental health
and social problems, metropolitan problems, and
epidemiology."
These centers differed in their responsibilities and in size;
some merely coordinated activities within the Institute, while others had
the capacity to directly support research and training and demonstration
projects, utilizing grant monies from existing programs in NIMH. As is
well-known, two of the centers grew to the status of independent Institutes
(Alcoholism and Drug Abuse), only to be later combined under the structure
of ADAMHA in 1973. (This was only after a three-month period when the
three Institutes had briefly joined the NIH, howeverl). The extramural
research program and manpower and training programs with which we are
particularly concerned here had been created as one of seven divisions
when NIMH became a bureau. This, too, was subdivided and branched on
several occasions to meet particularly the research needs of various growing
social programs. The intramural research program (which we do not focus
upon in this discussion) was also reorganized twice during the late 1950's.
However, the fact that its main research laboratories remained an integral
part of the NIH physical complex has lent stability to its research effort
despite a plateauing budget.
In summary, the past decade has seen almost constant organizational
change in the federal mental health administration. The rapidity and
complexity of these changes has frequently brought the organization to the
brink of chaos. Caught in the eye of the storm, both fiscal and
philosophical support for research has faltered.
139
Review of Recent Research Expenditures: NIMH and ADAMHA
As in other areas of biomedical research, over the past two decades
the most significant portion of research funding in mental health and
psychiatry has come from the federal government. What follows is a
comparative review of this funding base, particularly for the years 1969
to 1974 for which good statistics are available.
Table 1 (see below) compares HEW research expenditures in five
major areas. The mental health research figures include expenditures for
drug abuse and alcoholism in addition to the extramural research program of
the NIMH.
TABLE ONE
H.E.W. RESEARCH EXPENDITURES. 1969 - 1974 (in thousands of dollars)
1969 1970 1971 1972 1973 1974
Cancer Research
164.879 169,738 180,904
245.069 344.752
446,951
Cardiovascular and
pulmonary research
133,726 137,298 142,761
172.258 219, 1£
291.539
Mental Health Research
102,634 112.852 117,356 119,253 106.051 127,595
Neurological and
visual Research
102,680 103,907 109,949 118,520 129,193 152,38
Family Planning and
Human development research 53,798 56.458 71,595 83.960 103,815 125,100
FROM: Federal Health Spending. 1969-74 ; L.B. Russell, B.B. Bourque, D.P. Bourque, C.S. Burke. Center for
Health Policy Studies, Kational Planning Association. Washington, D.C., 1974.
It can be clearly seen that very little increase in mental health research
funding has occurred. Indeed, the figure of $127.5 million for 1974 is
inflated above that of 1973 only because impounded monies were released.
The past decade has also been one of considerable inflation. The figures
above are not corrected to show inflation rates.
lAo
After correcting for inflation (using a deflationary index developed by
the National Science Foundation) it is clear that the real increase in
available money for psychiatric and mental health research (including the
new appropriations for substance abuse research) was less than 5% between
1969 and 1974. Note the marked contrast between this situation and the
support for other areas of biomedical research effort over the same period
(see Figure 1 below). If anything, this gap has widened in the past tv/o
fiscal years (1975 and 1976).
FIGURE ONE* '
H.E.W. 1974 RESEARCH EXPENDITURES EXPRESSED AS A
PERCENTAGE OF 1969 EXPENDITURES
ACTUAL DOLLARS
INFLATION-CORRECTED DOLLARS
230
-
265
250
-
235
-
220
-
205
-
190
-
175
—
<
160
-
115
130
_
115
-
m
280
—
255
-
250
-
235
-
220
-
203
190
-
^
175
—
1
IGO
—
a.
-I
<
>
Its
y
S
5
O
3
'-'
s
130
~
I
<
3
d
Ub
—
S
"
■^
inn
f5^!55!
* Based on figures drawn from Table 1. For inflation correction factor, see
Federal Health Spending 1974 : Center for Health Policy Studies, National
Planning Association; Washington, D.C. 1974.
\k\
Turning now to the Extramural research budget of NIMH alone (not
corrected for inflation) it is seen that support for extramural NIMH research
has declined even in actual dollars . It is apparent that not only have all
new appropriations and expenditures for ADAMHA research been in the area of
substance abuse but that these expenditures have been at the expense of
other research effort (see Table 2 below).
TABLE TWO
ALCOHOL, DRUG ABUSE AND MENTAL HEALTH ADMINISTRATION
EXTRAMURAL RESEARCH
(in millions of dollars)
Fiscal
Year
NIMH
TOTAL
(% NIMH/ADAMHA)
Div. EMR
'Other"*
1971
53.1
12.6
65.7
(85%)
1972
51.6
14.9
66.5
(77%)
1973
53.6
13.5
67.1
(71%)
1974
48.5
19.7
68.2
(69%)
1975
47.5
17.3
64.8
(67%)
*(Di vision of Mental Health Service Research and other extramural
research, such as crime and delinquency, urban problems, etc.)
SOURCE: NIMH Statistics
Over the same time period, however, the total budget of ADAMHA was
rising steeply. Indeed, the expenditures for health services financed by
ADAMHA increased by 627% between 1969 and 1974 (see Table 3 below).
TABLE THREE
HEALTH SERVICES FINANCED BY ADAMHA.*
1969 1970 1971 1972 1973 1974
Outpatient and 50,857 55,355 77,246 223,833 262,401 319,167
other services
TOTAL INCREASE 1974/1969 = 627^.
* FROM: Federal Health Spending 1974 : Center for Health Policy Studies,
National Planning Association; Washington, D.C. 1974.
142
Thus, we see that at a time of increasing service responsibility
and a rapidly increasing total budget, the research efforts of ADAMHA
had plateaued or were beginning to decline.
Furthermore, looking at the expenditures within the extramural
research budget of the NIMH, one may see that a considerable percentage
of applied research effort is focused upon social research reflecting
ADAMHA' s overall social investment.
TABLE 4
DISTRIBUTION OF THE RESEARCH DOLLAR
WITHIN THE NIMH EXTRAMURAL PROGRAM, 1974. *
Expenditure in Millions
A. 'Basic Process' Research (35% of total)
Biological Mechanisms 11.4
Psychological Mechanisms ' 7.5
Sociocultural Mechanisms 3,1
B. 'Applied' Research (657- of total)
Social Problems (violence, poverty, etc.) 7.8
Normal Adjustment (adoption, marriage, etc.) 7.8
Schizophrenia 5.3
Depression 4.9
Learning Disabilities 4.5
Neuroses, Character Disorders 2,1
'Other' diagnoses (unspecified) 5.3
'Other" (unspecified) 3.3
TOTAL 63.0
* Ad&pted from the report of the research task force of the NIMH: Research
in the Service of Mental Health (page 45); U.S. Government Printing
Office, 1975.
1^3
Research Manpower Training
There can be no research of quality without a competently trained
pool of research workers. We have previously commented upon the late start
of the development of the manpower pool for psychiatric research and have
also highlighted the success of the research career development award
programs of the NIMH.
The development of a researcher is a slow process and begins in medical
school. Until recently, monies were available in the Psychiatric Training
Branch of NIMH to provide faculty teaching time and student stipends, the
latter being designed to encourage student research effort during summer
externships and fellowships. These programs were officially phased out by
the administration, but have been returned temporarily by the NIMH Training
Branch. The official administrative policy however, is again to remove them.
Faculty support has also been provided under the mandate of NIMH to
train clinical psychiatrists. These faculty form the role models for many
students and residents, some of whom will enter research. While NIMH and
ADAMHA have had fellowship training programs for research, only a very small
portion of them have gone toward the training of psychiatric residents in
research (approximately $500,000 out of a budget of $20 million). Considerably
more has gone to the training of graduate psychologists. In 1974, the
President's budget announced the administration's pUn to phase out this
program in addition to all the NIH training programs. While there has been
modification of this, and there are now general fellowship programs for
research, no specific support oT fellowship programs for research training for
psychiatrists is now available. The research career development programs are
also officially on the decline, despite their success as outlined earlier.
Hence, this brief review reveals a uniformly bleak picture - one of
a rapidly declining support for research manpower training in psychiatry and
in mental health. The cuts come at a time when a viable manpower base for
psychiatric research is in its infancy; at least another fifteen years of
vigorous support are essential if it is to become a basic health research
manpower resource. No matter how fascinating recent advances have been and
how promising are the research opportunities currently developing, there can
be no advance in our understanding without competent investigators.
Research as a Function of the Public Health
A research capacity investigating health and disease is a national
resource. It' is very difficult, however, to set priorities when limited
monies are available. How may one judge the potential impact of the
research dollar? Obviously, it is not just the mortality of a dysfunction
which must be considered.
Undoubtedly, mental illness is one of the leading health problems in
America today. During the past decade, nearly 40% of all hospital beds in
the United States were occupied by the mentally ill, and it is estimated
that in any one year, about one million Americans will become disturbed enough
to require psychiatric hospitalization. 4.5 percent of all live births who
\kk
reach the age of 15 will develop schizophrenia during their lifetime. Hence,
during the decade 1960-1970, 1.9 million individuals wore born who will enter
the care system with schizophrenia after 1975. One in ten adults will, at
some time during their life, experience a serious depi^essive illness, and
probably a third of these individuals will require hospitalization. A portion
of those with depressive illness will commit suicide. Suicide itself ranks
in tenth place as a cause of death across all age groups, and it is in the
top three as a cause of death in young people.
Psychiatric disorder usually begins in early or middle life. That
is earlier than most major diseases with a high morbidity or mortality.
The table below is an attempt to compare research expenditures in
cancer, heart disease and schizophrenia.
TABLE FIVE
H.E.W, RESEARCH EXPENDITURES:
RELATI0: ;S H1P TO THE NUMBER O F ! ! \'D1 VIDUALS IN CARE V.'lTIi SPFCII'IC DISORDERS
DISORDERS FOR WHICH ESTIMATED NUMBER i RESEARCH EXPERDIT'JRE
CAR F . R ECFL\^FJ UliDilLXARE BJ:£i:ARi:JiJi;:;££!JD,LTllBilJ,97Jl ttRJ?f.L;.SIitLJ.ij'in£3_Ci:2I
CANCER 2,200,000^ $4t|C.96L000 $203,16
HEART DISEASE 3.307.000' $291,539,000 $88.15
GEM. psychiatric" 3.200.000'' $127,596,000 $39.86 (f25,00)
SCHIZOPHRENIA 721.000* $5,300,000'' $7.35
SOURCES;
1) FEJ:[LR^Ul^ii)J:uJ^LiiI)I^'(Li%'Ua7tl; Center for Health Policy Studies. IIatior'al Planning
/issociation. washington. d.c. 19/ h,
2) Report of the National Panel of Consultants oh the Conquest of Cancer; Government Printing
Office. IIashington. D,C, 197^.
3) Prfvalfijce of Chronic Circulatory Conditions: National Center for Nealth Statistics. Series 10
mj 1972.
i\) Nll'ill figures (personal communication).
5) Report of Research Task Force of Nlfill; Research in the Service of Mental Health. U.S. Government
Printing Office. 1975.
• H.B.; The figure of 177.59G.000 for mental health research in 197'I (taken from reference n aecve)
presumably includes illf'iH intramural (approximately 17 million), extramural (o:j million), alcohol
(12.8 million), drug abuse (17.7 million) and some released previously impounded monies (1? MILLIC:;).
giving the total of 127.5 million. The figure of 3.2 million persons under psychiatric cane does
NOT include all individuals under care for alcohol and substance abuse, however. Hence, the figure
$39.85 FOR research expenditures per person under care is undoubtedly high, making the SITUATION
SEEM BETTER THAN IT REALLY IS. If THE NIIlH BUDGET (INTRA AND EXTRA MURAL) IS USED ALONE. THEN THE
FIGURE PER CAPITA UNDER CARE DROPS TO $25.00.
\k5
Admittedly such calculations are crude, but the difference between 203
dollars expended for e^ery individual under care with cancer when
compared with seven dollars for every individual under care with
schizophrenia is too large to be whistled away. Are we to conclude that
there is little need for new knowledge regarding schizophrenia? Is it
no longer considered to be a scourge upon the public health?
In summary, there is clear evidence that the fiscal support for
psychiatric and mental health research and for manpower training has
plateaued (or is being systematically withdrawn) just at a time when
the field is ripe for major advance. Furthermore no rational base for
this selective reduction in funding of mental health research is apparent .
The establishment of the President's Panel to review biomedical and
behavioral research represents a timely reappraisal of our national effort.
We believe that it is essential that a renewed commitment be made specifically
to psychiatric research , building upon the scientists and institutions which
have been developed over the past 20 years, and which only recently have
borne tangible fruit.
In addition to our earlier discussion, we base the recommendations
which follow ipon the following points:
a) that psychiatric research is currently moving rapidly and into
exciting new fields. There is no doubt that this effort and excitement can
be sustained, and that new individuals will be attracted to the field.
Hence, new monies can be both creatively and productively used.
b) that the medical schools, because of their unique position as
academic institutions vitally involved in the clinical care of the mentally
ill, have a critical role to play in this process.
c) that the efforts to stimulate research and research training in
psychiatry over the past 20 years have been productive, and offer a vigorous
model for directions to be taken in fostering the future growth of research
manpower.
d) that for optimum research potential, the components of scientific
excellence, a balance of research effort, the continued development of new
researchers, and a stability of the funding policy are all essential.
1A6
Recommendations
1) Some resolution of the apparent competition between support for
service and research within ADAMHA must be found. Research and service
should not be in conflict but the present administrative structure tends to
foster the growth of one at the expense of the other, thus bringing the
two goals into apparent conflict.
A potential solution lies in the separation of service and public
health effort within ADAMHA from that of the research .
Arguments for the separation within ADAMHA of the service programs
to combat drug abuse, alcoholism, and mental health programs are powerful.
The development of model service delivery programs for the three components
do require different skills and techniques, although the same treatment
principles run through each of them.
While there is a logic for the separation of these service components,
the fragmentation of research into these separate categories is artificial
and counterproductive, causing in many instances an overlap of effort. There
are larger common threads in the biological and behavioral underpinnings of
the addictions and other mental disabilities than there are dissimilarities.
Hence, we would recommend that research and training efforts in ADAMHA be
integrated under one leadership . Whether this should be a National Institute
of Mental Illness Research, separate from ADAMHA we consider of secondary
importance and open to debate.
It is essential, however, that service support programs, aids to
states, and demonstration projects of ADAMHA be organized separately,
and under different leadership.
2) A lack of stable research funding policy, with research monies
following fashionable trends, interferes with the development of a viable
research base. Hence, we would propose that a special advisory group for
psychiatric research be established , which is distinct and apart from the
National Mental Health Advisory Council. This advisory group, with a
membership of scientists and informed laymen, would help stimulate internal
critique and review within ADAMHA and help also to relate the state of
the art to national policy. At the moment, the maintenance of psychiatric
research is at the mercy of the public and administrative short-term whim
(witness the large effort in "social" rather than mental illness-focused
research) and O.M.B. policy. This lack of stability in funding erodes
efforts both within the Institute and extramurally. For example, recent
decisions to phase out training and research training monies appear to have
been made without the benefit of any informed consultation with the field.
Furthermore, new drives in any area of great public concern should be
supported with new money, and not mounted at the expense of existing research
(as has been the case with recent efforts in substance abuse). Such
147
capricious routing of available funds again erodes the stability and true
balance of the research effort.
3) As noted earlier, the past 20 years have seen the development
of a group of scientific investigators with specific competence in mental
health sciences. We must now seek to find a mechanism which continues
to build upon these efforts and to integrate them into the basic biological
and behavioral science opportunities to be found in the medical school.
In order to sustain a cadre of senior investigators, the se nior research
scientist av/ard concept needs continued development . In addition, a
continuation of and increased funding for the Career Development Award
program, which supports the development of young, excellent investigators
showing promise in the field of psychiatric research, must be undertaken .
4) There is much to be gained from the formal development in medical
schools of seminal research centers designed specifically to undertake
research into mental illness . Placed in various parts of the country, such
centers would be able to develop representative epidemiological information
and also utilize advances in understanding of both biology and behavior to
increasingly clarify populations at risk for schizophrenia, etc. Such a
task is difficult in the intramural program, and hence the two would
complement each other. In addition, these centers could become the focal
point for research training of a specialized nature. We believe that five
to ten of these centers are needed immediately, distributed throughout the
nation.
5) By recommending the establishment of research centers we by no
means wish to reduce the importance cf the ccr.tiiiucd provision of grants
and contracts to individual researchers in all medical schools on a
competitive basis ~ We would further seek to expand mechanisms (such as
the General Research Support Grant concept, GRSG) whereby beginning
investigators in all medical schools can compete with colleagues, preferably
at the local level, to seek seed funding for emerging ideas.
6) We advocate that peer review be supported and defended at all
costs. Despite criticism, the past 20 years has shown that this is
undoubtedly the best way to provide expert scientific guidance to that
administrative structure responsible for directing and molding the biomedical
and behavioral research and the educational effort of the nation.
7) We propose that the Directors of NIMH and ADAMHA be appointed
for a specified term and should not serve at the pleasure of the President .
This stability of leadership, freed from sudden and capricious changes in
organization by administrative fiat, would do much in turn to provide a
stability of science policy, free from the pressures of political expedience.
The ability to pay higher salaries for the senior administrators would also
ensure that the leaders of the field would be potentially attracted to the
most senior posts developing scientific policy.
September 1 , 1975.
litS
FEDERATION OF AMERICAN SOCIETIES FOR
EXPERIMENTAL BIOLOGY
Mr. Chairman and Members of the Panel:
My name is Arthur C. Guyton. I am Professor and Chairman of the Department
of Physiology and Biophysics at the University of Mississippi Medical Center. I
am also President of the Federation of American Societies for Experimental Biology,
and it is as a representative of that organization that I appear before you today.
The Federation consists of six societies: the American Physiological Society,
the American Society of Biological Chemists , the American Society of Pharmacology
and Experimental Therapeutics, the American Society for Experimental Pathology,
the American Institute of Nutrition, and the American Association of Immunologists.
All 14,000 members of these societies are deeply involved in and affected by the
problems this Panel has been called into being to examine. We await your findings
and recommendations with a great deal of Interest and shall be even more interested
in what is done about your report .
In the ten minutes allotted to me I could not enumerate all the problems before
this Panel, let alone presume to deal with them. Fortunately, it is not even
necessary to try. The Federation, through no fault of its own, is well represented
by working hands in your undertaking. I note that two of the members of this Panel
are members of ASBC, one of the constituent societies of the Federation. I also
note that five of the ten members of the Overview Cluster are members of constituent
societies, as are 75 of the 149 Individuals serving on the Interdisciplinary
Clusters. Additionally, I believe each of the constituent societies has or will
respond to your Invitation to submit written statements.
I think I should also note for the record that the Federation is not a trade
union, it is not a political organization, it is not a trade association, it is
not a commercial organization — it is an aggregation of learned societies which,
as a custodian of the scientific tradition, has as its primary mission the
development and dissemination of new knowledge in the life sciences.
U9
Let me now use what time I have left to comment briefly on a few things
uppermost in my mind. I may have little to say that you have not heard before
in the course of your meetings, but there are some matters on which I would like
to add emphasis .
Basic Research
First and foremost — Basic Research — the sine qua non. We were able to go
to the moon because the basic knowledge was there to apply and develop. The
National Cancer Institute has been in existence since 1937, but we are not even
going to find the front lines in the war on cancer until basic research brings
forth the necessary new knowledge. It is gratuitous to make this point with a
group of professionals in the field, but it is a point that needs to be hammered
home with those who demand a quick payoff by the next election or the next full
moon. There should be official recognition of the necessity for basic research.
National policy should commit to the support of basic research a fixed minimum
share of the funds appropriated for the National Institutes of Health. Otherwise,
with the approach of a National Health Insurance program and with the demands
for health services increasing and their costs already escalating out of sight,
it might not be long before funds for basic research will be found under
"miscellaneous" in the budget.
A special problem in recent years in the funding of basic research has
been the roller coaster method of Federal budgeting. I do not need to tell the
members of your Panel that basic research requires years of progressive develop-
ment, which obviously also requires a high degree of funding stability, long-term
funding, and funding that is assured several years in advance. In the past, many
of the granting agencies have recognized this, but, more recently, especially
because of the annual delay in coming to grips with the budget by Congress and
because of the ups and downs in the finally committed budget, this principle of
150
long-term and stable support is fading; with it are going many of our valuable
basic research programs.
A very good way to increase the stability of basic research support would
be to introduce the principle of "banking" into funding the National Institutes
of Health and the National Science Foundation as well as to introduce this
principle to the funding of individual grants. That is, if all of these were
allowed to carry over a certain percentage of their funds from year to year,
this would allow far more effective planning and would help to insure stability.
It would also allow important economies that cannot be realized when funds must
be spent on a rigid schedule in a fixed amount by a fixed date. This leads me
naturally to my second point.
Over centralization and Overcontrol of Research
Research in the life sciences is capricious . Discoveries cannot be requi-
sitioned, bought, or ordained. There is no way of telling which unknown
researcher in what laboratory in what part of the country will be some future
year's Nobel prize winner. I believe I am safe in saying that most of the great
discoveries in the health and life sciences have come from the genius, pure hard
work, and sometimes luck of individual scientists or small groups of scientists
who have pursued their projects relentlessly. Most of these persons have been
teachers in universities, medical schools, or other scientific institutions,
and in most instances they have contribued their time and their thoughts without
pay or with little pay. The research funds have been used mainly to pay for
technical assistance or to purchase supplies and equipment. My concern is that
before many years this kind of researcher may become extinct. That would be a
shame because he has given us an exceptional return on the research dollar.
The individual investigator is being crowded out of the pictire by changing
patterns in the funding and management of research, characterized by more and
151
growing centralized direction and control from administrative offices in Washington.
We see increasing use of the contract and "center" approach to health research in
which government control officers play an ever more decisive role in determining
what research will be done. We see Increasingly large awards to specific institu-
tions, contingent on their channeling their research efforts along specific lines.
We see the simultaneous establishment of too many parallel research projects
directed toward the same problems and goals, as defined by a central committee.
We could cite other indicators.
Such centrally directed research has a tendency to "buy" research workers
and to channel their endeavors into pursuits not compatible with their training
or with their motivation. In the process the spark of genius is lost. This
explains the belief of most research workers that a large share of the centrally
directed research programs has given our citizens and our nation only a fraction
of the beneficial results that could be obtained were the research workers less
constrained in the direction of their efforts.
We must find a way to keep the Individual investigator in the picture and
to continue to benefit from his initiative, motivation, genius, and hard work.
We must also insure that the innovative and creative youngster has an opportunity
to contribute at all times, whether funds are short or plentiful.
How Important is Targeted Research ?
Closely allied to the above topic is the basic question: "How important is
targeted research?" I agree very strongly with a statement made recently by Dr.
Edgar Haber, Professor of Medicine at Harvard Medical School and published in the
medical scholarship journal The Pharos : "If all the relative discoveries were
Immediately taken from the clinical laboratory and widely applied in physicians'
offices or hospitals, it is doubtful that a significant effect on mortality
statistics would be apparent." Dr. Haber went on to explain that the major impact
152
on life span since 1900 has depended almost entirely on our success in conquering
or partially conquering infectious diseases. This came about through slow develop-
ment of the principles of microbiology. Immunization, sanitation, and the science
of antibotics.
Therefore, our ability to make real progress In the health problems of
today seems to depend not so much on application of principles already known
but instead on achieving breakthroughs that will provide the yet unavailable
scientific bases for conquering cancer, heart disease, and other diseases that
have thus far defied the research scientist. At present, there Ls no reason
to believe that a "targeting" committee can determine better what avenues to
pursue in quest for these breakthroughs than can the multitude of individual
scientists themselves. Therefore, it is my hope that the genius of our
scientists will receive a high level of support in preference to granting this
support to "applied" projects.
Training Support
Next let me turn to a matter on which the community has been subjected to
a lot of turbulence, ambivalence and vascillation — the matter of training
support. We do not have to look far for a sound precedent and rationale for
this support. The nation assigns a high value to its physical security. It
knows it cannot look to state, municipal, or private interests to provide for
the common defense — it is a matter for which only the Federal government can
assume responsibility on behalf of all the people. To assure that adequate
numbers of appropriately trained individuals are available and committed to the
multitude of tasks involved, the government has underwritten the cost of the
Department of Defense educational system, the largest educational system in the
world. This system embraces all levels of education and an infinite variety
of skills and knowledge.
153
The parallel between the physical security of the nation and the health of
the nation is self-evident. As with national security, a high value must be
assigned to national health. Obviously, no state, municipal, or private interest
is able to mount and coordinate an effort of the scale necessary to develop
essential new knowledge on the frontiers of science, nor should it be expected
to assume such responsibility on behalf of the nation. Only the Federal
government is able to assume this burden on behalf of all the people. If the
Federal government does not do it, relatively little of this essential work
will get done. And the work will not get done without people trained to do it.
Many members of FASEB are especially concerned about the direction that
training support has taken, namely, support in highly targeted areas. Here
again there is the element of central control that has many shortcomings —
sluggishness of response to the needs of the times, herding of trainees into
areas for which they are not motivated, loss of the element of genius in the
trainees, and many others. This approach, in effect, assumes that a few persons
know better than the great body of life scientists what is needed in the way of
training. I highly question this, and would like to submit that the principle
of allowing the intellectual genius of our scientists complete freedom of
expression has been one of the most important factors leading to the present
preeminence of American science in the world.
Peer Review
Peer review is a subject that continues to get the benefit of critical
attention, most recently in oversight hearings of a Subcommittee of the House.
And I understand that Congress has asked your panel to look at this subject as
one of its major points of deliberation.
I would like to suggest that any type of review besides peer review is not
a review at all. For who else is qualified to evaluate the scientific premises
and the probability of a worthwhile product besides one's peers who themselves
can understand the research proposals and their value? Even if Congress should
become the final adjudicator of research awards, its judgement would still have
to depend on peer review somewhere along the line, or the awards would be
meaningless.
Therefore, the question that must be answered about peer review is not
whether or not It should be continued, for there Is no substitute, but.
Instead, whether or not the present mechanism of peer review is the most
effective.
Many members of FASEB believe, on the basis of long experience, that our
present system can hardly be improved. But it is my own personal belief that
we must continue to evaluate the peer review system year after year and to
evolve it into a progressively better system as we find faults. The only fault
I believe I can Identify at the present time is the possibility that the peer
review system perpetuates support and growth of the established centers while
research of the same quality may not be supported in like measure in newly
developing areas of our nation. There are many philosophical reasons for
believing that broad dispersion of our Intellectual potential would in the
long run be more productive than aggregation in a few centers. However, this
is a judgement that is based on my own personal philosophy. If we should all
agree that this is a problem with the present review system, very simple changes
in its present mechanisms could easily achieve the desired result.
The Scientific Community and the Government
Finally, I would like to speak for a few minutes about the relationship of
the scientific community to the government. The time has come, I believe, that
we should have an Independent Deparpment of Health unencumbered b^ the morass
of difficulties facing our national welfare apparatus. This perhaps would be
155
an effective way to establish more effective communication between the biomedical
scientific community and the governing powers. However, regardless of the
mechanism, in this day when science plays an overwhelming role in the welfare
of our nation, it is almost inconceivable that we should not have a highly
developed scientific advisory apparatus for advising both the President and
Congress. Therefore, I hope sincerely that this Panel will address itself
deeply to this problem. And while establishing communication with the
government, it would be worthwhile to establish as well an effective means
for communication between scientists and the public.
In traveling here from Mississippi to appear before you for ten minutes,
I had no illusions about what I would be able to contribute, but I wanted to
make the trip because it gives me the opportunity to thank you personally as
well as on behalf of the Federation and the biomedical research community for
the work that you have undertaken. I hope sincerely that the results of your
efforts will lead to a stable and progressive biomedical ^icientific policy for
mr nation.
I shall be happy to try to answer any questions you may have.
156
THE JOSEPH AND ROSE KENNEDY INSTITUTE FOR THE STUDY
OF HUMAN REPRODUCTION AND BIOETHICS
Mr. Chairman and Members of the Commititee:
My name is Andre E. Hellegers. I am an obstetrician and I am presently
Director of the Joseph and Rose Kennedy Institute for the Study of Human Repro-
duction and Bioethics. In that capacity, I correlate the work of three
university divisions: the Laboratories of Reproductive Biology, the Center for
Population Research (Demography) and the Center for Bioethics.
While I've been asked to testify as a concerned private citizen, I do so
from an odd perspective. I have successively and often simultaneously been an
obstetrician and fetal physiologist, as well as a lecturer in Population Dynamics
at Johns Hopkins University and Georgctovm University. I have served as a
member of the National Advisory Council of N.I.C.H.D., as a member of the Human
Embryology and Development Study Section at N.I.H. , as a consultant on social
aspects of obstetrics to Secretary John Gardner, as a technical consultant
to the Population Reference Bureau, as President of the Society for Gynecologic
Investigation and of the Perinatal Research Society, as Deputy Secretary General
of the Papal Commission on Population and Birth Control and as a member of
President Johnson's Committee on Population and Family Planning. In the field
of ethics, I have served as a consultant to the A.M.A. , the American College
of Obstetricians and Gynecologists and to N.A. S./N.R.C. I recite the facts
only to point out that I have been involved with the subject of reproduction
and population from the perspective of church, and of state, from the private
sector and the government sector, from the individual physician's and from the
professional society's.
For your information, I enclose an article I wrote for the Linacre Quarterly
the Journal of the Philosophy of Medicine of the Catholic Physicians of the
United States. It is not exceptionally profound, but what is of interest is that
it was voted the Linacre Award as the bast article of the year. I urge you to read
157
it because it deals with much of what I'll stress today. The Award will
simply tell you that catholic physicians thought the ideas worthwhile.
Briefly, the issues in population and family planning are twofold:
1. I'/ho wants how many children, when, where, and why? And what is
their quality?
2. How can people achieve their goals in human reproduction?
Encompassed within these two questions sit such socially, and politically,
explosive issues as the population explosion, pollution, contraception, abortion,
and they also deal with and depend on controversial issues such as economics,
quality of reproduction, racial prejudice, sex education - in brief, all those
things from which politicians prefer to steer away. That makes it particularly
important that you and I as non-politicians address ourselves to them.
Let me start with question number two first. It is the subject of biology
and family planning. We know the reproductive process can be impacted at the
level of the hypothalamus, the pituitary, the ovary and testicle, the tubes,
endometrium and cervix. Among the tubes I obviously include the vas deferens.
It is a fact that we know very little about the basic biochemical mechanisms
of these organs. It is not surprising. Departments of Obstetrics and Gynecology
have never been considered hotbeds of biological research in medical schools.
And you know as well as I that in departments of Physiology and Biochemistry, the
cardiovascular system, the renal system and the central nervous system are given
precedence over the reproductive system. It is true in our universities. It is
equally true in our pharmaceutical industries. And so our family planning has
the "sophistication" of condoms, of foams and jellies, of diaphragms, of foreign
bodies in the uterus and of pills which act on virtually all body systems. Neither
should abortion be considered precisely elegant. V/e are fast approaching the
stage where for every two women dying from childbirth, one woman is dying from
family planning. This disgrace should stop. Obviously, the need is for
extensive study of the reproductive process, and especially the enzymology and
158
biochemistry o£ the menstrual cycle at all levels. It is highly no n- controversial
research, for it will lead both to better artificial contraceptives and to
better natural family planning methods, thus being acceptable to all religious
persuasions. Moreover, I know of no one who does not favor contraception over
abortion. Lastly, it serves that forgotten constituency in the nation which
has infertility problems, and which is invariably victimized by the perfect
family planning of others through a scarcity of adoptable children. In brief,
there is a large constituency for this field of endeavor and a broad ethical
consensus for such programs. I would go further. I would say it is an ethical
imperative.
Let me turn next to question number one. It deals not with the biology,
but with the sociology of reproduction. Anyone with an iota of insight knows
that the questions of population expansion and of family planning should not be
confused. If perfect family planning methods existed and ail Americans decided
to have four children and achieved precisely that, population would expand at
an astonishing rate.
The sociology of reproduction deals with the quantity and quality of
reproduction and the factors affecting them. The nation as a whole gathers
vast statistics in this area through the Census Bureau, the National Center
for Health Statistics and numerous other agencies. These data cost tens of
millions of dollars to gather. But the simple fact is that there is hardly
any money to analyze them. Funds for the study of the sociology of reproduction
come under the politically unfortunate name of "Behavioral Sciences Research"
in the C.P.R. budget of N.I.C.H.D. The total available funding is $7 million -
an absurd figure when we profess a deep concern for a population- explosion, for
the health of our children and when we hear ringing denunciations of the fact
that we are 13th (or whatever) in infant or perinatal mortality (or whatever).
These are meaningless statements implying inadequate health care, when we all
159
know that age-specific-parity-specific mortality has never been comparatively
analyzed between countries, so that it is quite impossible to know which
differences are due to health care problems and wnich to the sociology of
family formation. Without such analyses it is also impossible to judge the
effects of large scale national and state investments in maternal and child
health programs. To compound the problem the National Center for Health
Statistics is years behind in getting its data out. Therefore, by the time a
study of published data is completed, it is usually five years out of date.
The data are stuck in the computer and neither the federal agencies nor the
private sector can get them out.
I urge this panel most strongly to recommend a marked increase in the
nation's capacity to publish updated health statistics. I also urge it to
markedly increase the funds available for the analyses of such data in the
area of human reproduction.
To summarize: if you believe the problem of population growth (or sudden
contraction) has grave social implications; if you believe the sterile have
problems; if you believe abortion is a problem which divides the country; if
you believe the quality of reproduction should be a major concern, then I
suggest that you recommend:
1. An upgrading of our ability to gather and publish updated statistics;
2. An upgrading of our ability to analyze the data through the "Behavioral
Science" component of N.I.C.H.D.;
3. A marked increase in expenditure in the area of fundamental reproductive
biology research;
4. The training of such analysts and of such reproduction biologists.
I said at the beginning that these scientific fields are potentially explosive.
The remedies I suggest are precisely noncon trovers ial and will do much to obviate
the explosiveness of the ethical issues.
160
Reprinted from The Linacre Quarterly, Vol. ^0, No. 2, May, 1973
Population, Rhythm, Contraception
and Abortion Policy Questions
Andr6 E. Heilegers, M.D.
riic recent .Supreme Court abor-
ticiii tleeisitni lias caused a great
deal oT anguish in Catholic circles
as \vell as in some others. It is too
soon io judge the effects, but it
may be confidently predicted that
attempts to amend the Constitu-
tion will be made. Since that is a
long pr(ieess, and since it is likely
to be tried again and again if it
tloes not succeed at first, it is clear
that for several \ears there \\\\\ be
much public bitterness m the en-
tire area of human reproduction,
"let while the abortion debate will
rage in all its bitterness, sve cannot
au'Kl other issues in human repro-
duction, in fact this may be the
\ery best of times to reflect on
what should be done and to recog-
nize that many things should have
iiecn done long ago. Our past neg-
ligence comes out all the more
clearly and our future needs seem
all the more obvious.
\\e must recognize first of all
that the world is presently under-
going an unprecedented rate of
population growth. In a sense it
is a gigantic medical success story,
overwhelmingly due to a massive
international reduction in infant
death rates. We used to bury the
problem by burying our children.
Now we save them and they be-
come the parents of further chil-
dren. 1 he very rate of the success
is ihe problem. Death rates of 10
per I ()()() and less are now wide-
spread in the developing countries,
excluding parts of .Africa. Obvious-
ly if birth rates continue at levels
of 40 per 1000, Ivpical of coun-
tries where family planning is not
\et in vtigue, growth rates of ?<0
per 1000 or three percent will,
and do, occur. This yields a dou-
bling of populations in less than
25 years. Common sense tells us
that this cannot long continue.
It may be argued that this is of
no concern to the United States —
that recent figures clearly show
we have our reproduction under
control.
Two points are to be stressed
in this regard. The first is that av-
erage family size in the late I920's
and 30"s was no greater than today,
yet it was followed by the baby
boom of the I950's. What we are
seeing today may simply be a de-
lay in the having of a first child
Dr. Heilegers is the Director of
The Joseph and Rose Kennedy
Institute far the Study of Human
Reproduction and Bioethics. He
si(i;i^'esis positive steps that the
Catholic Church can take in deul-
intJ with the prohlent of overpop-
ulation and reproduction.
Mav. 197^
161
and a delay in marriage. Just as
in the I950"s v^e suddenly decided
to marry and leproduce earlier.
The devastating population ex-
panding effect of early marriage,
or rather chiidbearing, is schemati-
cally presented in Table I. Here in
both families A and B, a boy and
girl are aged 20 in the year 1900^
They are to have four children
each, as do all of their descendants.
All die at age 70. The only differ-
ence between them is that family
A has its children at age 20 (quad-
ruplets in the first year for mathe-
matical simplicity's sake! In family
B they have the quadruplets at
age 30). Nothing more devastat-
ingly shows the dire effects of
early reproduction with close pack-
ing of generations. Any tendency
to delay chiidbearing, if it occurs
fairly suddenly, will yield data on
average family size for a given
year which are deceptively low
until the children are ultimately
had. One present possibility is that
we are turning from Type A into
Type B families, without it nec-
essarily meaning that we will only
have the mythical 2.1 I children
suggested by advocates of zero
population growth. First then,
we should not be blinded to the
real possibility of marked growth
in U.S. population on the basis
of the trend during this decade.
We did grow from the iy20's to
the 1950's and surely it was not
because we knew less about fam-
ily planning in the I950's than in
the 1920"s that we had more chil-
dren in the 1950's.
The second point is that there is
no reason for complacency among
Catholics when laniily sizes of two
are reached. \\e know from many
surveys that this is produced over-
whelmingly by methods other than
rhythm.
We must therefore acknowledge
that four facts are to be of concern
to the Catholic community:
1 . There is, on a world-wide ba-
sis, an unprecedented rate of popu-
lation growth;
2. The United States may well
go back to the growth rates of the
"i9S0's;
3. If the United States or (he
rest of the world were presently
to reach a family size of two chil-
dren, it would be in spite of the
teachings of Hiinuinue Vilae;
4. Early marriage and reproduc-
tion have a devastating effect on
population growth, as they are
also shown to be associated with
markedly higher divorce rates.
It would be my suggestion that
in the middle of the abortion acri-
mony we try to do what we shoukl
have done long ago, cooperate with
all others of goodwill to diminish
the magnitude of the abortion and
other problems. This is all the
more important since 1974 hits
been proclaimed "Population Year"
to dramatize the world population
problem. It could easily degenerate
into an abortion debate and mask
very positive steps that could be
taken by the Catholic community
and its leaders.
.Action Needed
We should constantly keep in
mind some simple biological facts.
Conception occurs from bringing
sperm and ovum together. Rhythm
aims at keeping sperm and ovum
Uii.iili.rly
162
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163
;ip,irl uitliout iliugs or a|ipliaiiccs knowledge o\' sperm, ovum and
while niaxiniizi'ig the possihililies nienstrLial physiologv. 1 inelutle
of intercourse. ■Artificial" contra- the cure of sterility since the sterile
cepti\es are aimed at interposing invariably will pay the price Iit
a harrier between sperm and ovum perfect fertilitv control whether
or destroying either. by perfect rhythm, peitect contr.i-
In order to bring any of these ceptit)n or perfect tibortioii, since
priicesses fidly under human con- there will be no children to adopt,
trol, we need basic research in re- I'his research in reproductive
productive biology. Put more clear- biology is immensely expensive,
ly: Those interested in curing ste- No private or religious founda-
rility, in enhancing fertility, in per- tion can support such work by it-
lecting rhythm or in producing self. It requires major federal
contraceptives or abortifacients funding.
require the selfsame fundamental Table II shows national e,\-
lAiu I-; II
IKDKKAI, SII'I'ORI <tl F\MII\ I'lANMNf; SKKNICKS AND
I'Ori I.AllON KKStARCIl
(l. S. in Millions of Dollurs)
(est.)
f-iimily I'liinning .Services I9h7 l4hS 1969 1970 1971 1972 197.?
1. (IFO Kiiniily I'lanning I'rojccl
dranls 4.1 S.."; l.t.S 22.0 2.^.2 24.0 1.^.0
2. DHKW Family I'hmninu
I'rojccl C.ranls .. .. 12,0 22, K .v? f> 9S.9 140.0
.>. DHF.W C OnipiL-htfnNivc M.iU-rnliy
and infant (arc I'rojcets Z.'^ 2."^ 2..'i .'.0 - - '
4 DHFW Malernal ami C hild
HeaKh Program 2..> ."* ■; }.f: .r.s 170 17.0 17.0
5. Other 2.2 1.."^ 2..^ 4,0 f>..'> K.7 10.6
TOTAL II..? 160 .M .? .^s.,^ HO." I4K.6 1S2.6
Research
1. Reproihiclivc Biology ami
( inilt accplivc Developmcnl
Basic Research 4.7 .S.6 4.K 7..t 7 S
Oircclcd Research - — 1.4 }.9 .? X
I'roduci [5cvelopnienl , -- --- --- --- 2.2
2. Tcsiing Medical FITcctsor
Awiihihle Methods
}. Behavioral .Sciences
4. Manpower Developmcni
Uraining)
.■5. i'opiiljtion Research C enlcrs
6 Federal .Agency Suitling (
0.7
\ }
1.6
0,2
1.0
2.1
2,1
2.4
2,7
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7
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4.2
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3.5
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F.
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16^4
|iciKliturv.'s for t'luiiily pliinning be phased out.
■-crviccs aiKl research by the VS. hi brief, it is clear that if the
ucnenimeiit (excluding fi>reign Catholic community means what
anl programs). It will be immedi- it sa}s in opposing abortion and
atelv afiparent that the family plan- artificial contraception, and if it
ning ser\ices have markedly in- is at all honest in its interest in
creased. In other countries these perfecting the rhythm system, it
services \sould never have been has been derelict in its duty. An-
lisled in a budget related to the nually appropriation hearings arc
population problem. They uould held in the Congress, innumerable
be included under health insur- lobbies plead their respective causes,
ance schemes. It nec^s little imag- Representatives of the Catholic
ination to add U.S abortion costs hierarchy have pled their many
to tliese figures and see that we causes without hesitation,
annualh spend very large and in- ^'et to the best of my knowledge
creasing sums on the rendering o( there has never been a move on
services o{' which official Catholic the part of the official Cathiijic
teaching hardly approves. Church to demand an increase in
Compare these costs with the expenditure of funds in reproduc-
cxpenditures in reproductive biol- tive biology until the problem of
ogy, here called "contraceptive de- rhythm is solved. No Catholic bish-
velopment ■" These are the funds op, to my knowledge, has asked
used to study sperm, ovum and for the funds to study the demo-
menstrual physiology. It is from graphic tactors and non-biological
these tunds that the solution to solutions to perceived population
rhvthni must come. problenis.
Compare these figures also with If today suction bottles, curettes
the Items listed as behavioral sci- and saline are decried in Catholic
ence. Ill-named, these funds are circles, we must accept our share
supposed to finance the study of of the blame for not having lob-
Ihe entire nature of the popLila- bied for the alternatives,
tion problem — its sociological. We shall also have to recognize
demographic, psychological and that we have done very little ti>
economic antecedents, processes counter the trend to early marriage
and consetjuences. The population antl reprotiuction with its high
research centers, and the training attendant population grt)vvth anti
of experts in the area, obviously divorce rates. Wc have done little
show in their fuinling that we are to spearhead the admission of vvom-
more intcresteil in doing things en to colleges and jobs which can
than in analv/.ing whether v\ e are be ellective in delaying childbear-
(.loing the right things or whether ing. Indeed we have tended to (ip-
vve ought to be doing additional pose those trends which could
or different things. Moreover train- have helped to alleviate the prob-
ing pri'grams have reccntlv been lems we now lace,
entled. aiKl the study centers will It may be argued that support-
165
ing research in rcprodLlL■ti^c hlnl- 3. Th;\t the \';itican represciUa-
cigy iiKi) lcai.1 U' birth coiUml iiieth- lives at the t>rticial inlernaliuiKil
(xls the Chureli opposes, including conferences ol' the I'mted Nations,
c,irl\ ahorlitacients. But ultimately during the l'-^74 ['cipulation \ ear.
we shall have to show that respon- take the lcai.1 in advocating pro-
sible parenthood as we under- grams to tielay age at marriage. In
stand it is a viable alternative to so doing, all those interested in
what presently reigns. Whether the lowering population growth rales,
knowledge required can also be divorce rates and in improving (he
used in Wiiys of which we do not opportunities lor the education and
approve shotild not. under the development o\' women's talents
principle ot tiie double et'lect, re- could make common front.
strain us from pushing for the 4. That Catholic leaders. Iiierar-
knowledge which can be used chical and private, encourage Cath-
propcrly. We do not oppose atomic olic foundations to foster the es-
research because it may produce tablishment at (alholic universi-
better bombs when we know it ties of major research centers in
may solve the energy crisis. problems o\ population, reproduc-
, . tion and the familv. Major Catholic
Kecommendutions , . . ', , , ,, . ,
lay orgamzations like the Knights
I would make several recom- of Columbus and the NatiiMial
iiietidations which I believe long Catholic Council vt' Women and
overdue: Men should have taken the lead
1. I hat the olliciLiI Catholic in this years ago instead of just
Church strongly lobby lor in- (apposing abortion retrospectively,
creased expenditures in reproduc- s. That while Catholics may
tive biology research. Presently have serious dilferences with non-
Ihe administration spends less than Catholics on other issues, they rec-
oiie-lhird of the funds recommend- ogiiiz.e. as has been sh(>wn bv
ed by one study committee after pi>lls and relerenda. that there are
the other. The President's personal- many other secti>rs of the A\meri-
ly stated repugnance of abortion can public who consider abortion
should he an indicator of his will- a less than desirable, if not re-
ingness to concur in such expendi- pugnant. procedure, and th.it they
tures. Certainly more human lives should make common tront wiih
will annually be lost thrviugh abor- these sectors wiihout recrimina-
tion than through cancer antl heart tion about lesser issues.
disease combined, yet these are 6. That the Supreme Courts (.le-
the ma|or areas of research e.\pan- cision shouki be viewed not |ust
s'lon today. as a tlisaster. but as an opportunitv
2. That tlemographic research to relied upon our own deficiencies
which is at the heart oi the na- in the solution o\ problems which
ture o\ population and reproduc- we have lor too long avoided and
tion problems he stronglv support- must now take the leai.1 in correct-
ed bv the ollicial Church. ini;.
(^u.iiieily
166
NATIONAL ADVISORY MENTAL HEALTH COUNCIL
9/30/75
Introduction
On September 17, 1975 I completed four years of service on the National
Advisory Mental Health Council. During this period the old NIMH was split into
three institutes; the new NIMH, NIDA, and NIAAA, and these were placed in ADAMHA.
I have therefore been close to the operation of NIMH during this change, and
since the split, the NIMH Council has been called on to review grant applications
for NIDA. I would like to make comments on four issues that I believe are
relevant to your deliberations ;
1. The balance between biomedical and psychosocial research.
2. The level of funding of research supported by ADAMHA.
3. The importance of research training for an effective use
of research money by ADAMHA.
4. The appropriate organization for mental health, drug abuse,
and alcoholism activities.
167
I. The Balance between Biomedical and Psychosocial Research
It is possible that scientists with different backgrounds will always defend
their own turf. If I am to comment on the balance between biomedical and psycho-
social research in NIMH, I must admit that I, like everyone else, have my biases.
The only justification for my comments is that I have had an overview of all the
research supported by NIMH because of my role on the Council, and as a research
administrator I talk to scientists with many different types of training.
I think it useful to think of research in a two-dimensional matrix. In one
dimension, we have the categories biological, psychobiological , psychological,
psychosocial, social, and biosocial. In the other dimension, we have the applied-
basic continuum. This dimension I prefer to separate into three major categories:
a. Descriptions and evaluation of existing mental health delivery systems
and evaluation of slight modification of existing operations (epidemiology,
demographic issues, biostatistical data, descriptions of our institutions and
their organization, what they do, how successful they are at both the public
health and individual client level v/ith both prevention and therapy) .
b. Studies of causes of specific identifiable problems (research on the
causes of disease, and of the psychological and social problems that are
analogous to disease. I accept the underlying assimiption that there is such
a thing as pathology, although it may not all fit cleanly into the medical
model) .
c. Detour research into how things work (this research is basic in that
it is a necessary means to the solution of problems at level b. It is also
useful in a more general sense because it may apply to a number of specific
problems. It is nondirected only in a very special sense because it is not
targeted toward a specific disease, but is a means-end chain that leads to
solution of problems at the b. level) .
168
This matrix is like a playing board in a gambling game. If we have one
hundred chips, we must make a distribution of these chips in some way. It is
a gamble because we don't know the outcomes of any of the research.
Our options are as follows :
a. We can distribute our chips equally in all boxes;
b. We can put proportionately more chips in one of the disciplinary •
categories than in the others;
c. We can put proportionately more chips in one of the second-
dimension categories than in the others;
d. We can make an unequal allocation in both dimensions.
In my opinion, it is necessary to think through criteria that might prove
useful in making this allocation. I have considered the following:
1. It makes no sense to me to distribute our resources equally. To
do so would mean that we do not feel capable of evaluating the
different types of research or that we are simply incapable of
making trade-offs.
2. An allocation of at least some resources in each of the boxes is
required. It is evident that we have serious problems that can be
studied only by each of the disciplines, and some that require
mixes. Furthermore, we badly need information at all three levels
in the other dimension.
3. We should look at alternative soiirces of funding. For instance,
NSF funds psychological and social research. This means to me
that NIMH can reduce its funding in this area. NIH funds some
biological brain research, but in my opinion, not adequately enough.
There is a real shortage of funding for good descriptive and evaluative
research. The problem is that mere funding does not make this
research good. No one else funds disease-related research on
causes and treatment of mental illness . Therefore NIMH should
put more emphasis in this box.
169
4. We should put more money where a critical discovery is a real
possibility and will open up whole new possibilities. It is my
opinion (perhaps biased) that at this moment in history critical
discoveries will occur in biological research, and that they are
not likely to occur from psychological and social research.
5. We should put more research money into those areas where the research
problem is clear and manageable with present methods and tools. It
seems to me that biological research is at present much more
manageable than psychological and social research. Furthermore,
basic research is more manageable than disease-oriented or descrip-
tive-evaluative research. This poses a real dilemma. We need
better descriptive-evaluative research. How do we get it when the
research now being done at this level is really not very good? If
we support only basic research on manageable topics, research on
diseases and at the descriptive-evaluative level will not be
advanced at all.
6. We should support that research where we have capable scientists.
This criterion would again lead to a bias against descriptive-
evaluative research.
In summary, it seems to me that ADAMHA must put some money in each category,
but that the problems in the different categories are different and that the
allocation issue is not the only problem to be faced. Money is more likely to
be wasted if it is put in the descriptive-evaluative areas. This will not be
handled by more or less money. It will be handled by better training of researchers
to work in those areas and by better preliminary problem clarification to make the
money spent more useful. I personally recommend more staff planning in the
descriptive-evaluative areas, and planning grants that permit consortia to develop
large but highly selective grants with a lot of input by people with special
knowledge. For several of the reasons listed above I favor a bias toward the
biological side, but not to the exclusion of the psychological and social. I
strongly encourage continued support of basic or detour research in the brain
sciences because a dollar spent there has the greatest potential for moving
toward a critical discovery.
70
I believe that in all these areas of research it would be advantageous if
there was more and better program research planning. We need more professionalism
in mental health research. Centers and institutes might help but they can't be
turned off if they don't work out. I favor a support mechanism that encourages
groups to begin with project support and then move to program support, thiis
permitting the build-up of personnel and equipment. There should be guarantees
that support will not be stopped abruptly; however, the possibility of termination
for nonproductivity shoiild be present. Tenure in universities must not be allowed
to "freeze in" unproductive individuals in programs.
II. The Level of Funding of Research Supported by ADAMHA
In previous testimony the appropriation trends for research in the mental
health, drug abuse, and alcoholism areas have been presented to you. Although
there were steady increases from 1953 to 1975, there has been a real leveling
off since 1968, and, with increased costs created by inflation, it now looks as
if the amount of research supported will be reduced. I would like to join many
others who believe this is a shortsighted policy. I do not believe money should
be taken from NIH to support ADAMHA, but I do believe they should receive
approximately equal treatment. I hold this opinion for the following two reasons:
A. Many diseases for which there is currently a great expenditure of funds
are primarily causes of death. I seriously question whether it makes
sense to try to prevent death when at the same time there is so much
disability from chronic diseases, including the serious mental dis-
orders. In my opinion, we should try to improve the quality of life
and the productivity of those now alive. I think every citizen in the
United States ought to take a walk through some geriatric wards in our
state hospitals, or visit nursing homes, and see the elderly with senile
and arteriosclerotic brain syndromes being kept alive by antibiotics.
B. Recent work on the major psychoses is promising. If it is successful
it might prevent or radically alter the course of these conditions
and really make a contribution to the welfare of many people.
The conclusion seems obvious that we must not reduce support for research that
can make a real difference in the incidence and prevalence of serious types of
chronic disability.
171
III. The Importance of Research Training for An Effective Use of Research Money
In the last few years we have begun to think seriously about the relationship
between the size and characteristics of our training programs and the number of
individuals doing skillful research. I think it is certainly proper that this
evaluation has finally begun, but there are several trends that are disturbing.
In the first place, those who think primarily about budgets do not seem to
be aware of the amount of training required to produce skillful scientists. A
college experience, a predoctoral experience, and a postdoctoral training period
are all essential for those investigators who should form the core of the research
teams. All three levels of training should be adequately supported. The investi-
gators working in the mental health field are , on the average , not quite as
sophisticated as investigators in some other areas of biomedical research, even
though there are important and instructive exceptions . Some of the research now
being supported that is perhaps not quite as good as it should be, is below
standard because the investigators have Ph.D.'s or M.D.'s, but have not had an
intensive research training experience which both eliminates the ones who are
inadequate investigators, and which supplies interdisciplinary and methodological
sophistication. The intramural program at NIMH has been unusually effective in
giving this postdoctoral training in the mental health field. We should certainly
continue to see that it has this opportunity and support the other research
training activities of ADAMHA at all levels .
Secondly, there are those who believe that a scientist who is competent in
one field, say biochemistry or psychology, is automatically qualified to work on
problems that require sophistication in several disciplines, particularly on
problems that bridge the biology-behavior gap and that deal with behavior
pathology. I believe this is not so. There are now a number of young scientists
with real competence in two or more of the sciences relevant to behavior and their
effectiveness demonstrates the importance of this interdisciplinary training in
depth. In my view this is an argument for keeping the NIMH intact with its many
disciplinary interests, provided the quality of research training is maintained .
It seems to me that the training in neurobiology and some of the related behavioral
fields has been more successful in combining intense postdoctoral training with
true interdisciplinary experience than some other fields in psychology and the
social sciences. The postdoctoral program is not yet well established in these
172
fields because the predoctoral program that produces teachers who have at least
done a dissertation is seen as adequate. This has contributed to lack of follow-
through in some of the research in these fields and perhaps to some research
projects that seem to be somewhat trivial. What I am arguing for is an intensi-
fication and extension of the training for individuals in all disciplines relevant
to mental health.
IV. The Appropriate Organization for Mental Health, Drug Abuse, and
Alcoholism Research
A. ShoiiLd there be three institutes for research on mental health, drugs,
and alcohol?
I have always been opposed to the separation of these three components of
the old NIMH. I suppose that the separation is now a political reality and perhaps
cannot be changed; I also know that there are separate and powerful constituencies
that support each of them, and that prefer the separation. I also know that there
are reasons for believing that funding will be better if they are separated.
However, the two substance abuse areas share most of the features of the mental
health problems. At the service level, there are many reasons for keeping them
coordinated. At the administrative level, the separation has forced some
reduplication of functions in the three institutes and reduced the size of staff
needed to perform many important functions in NIMH. For instance, biostatistical
and epidemiological studies should certainly be coordinated.
At the research level, the separation is particularly unfortunate. Each
institute already faces the problem that there is a great range of research that
is relevant. Separation means either duplication occurs in the special areas
or there is a reduction of effort in some of the areas. Of course, research
on causes of the problems, and on methods of prevention and treatment, would be
handled by separate, initial review groups in any case. However, much of the
basic biological research and research on social problems seems to me to be
equally relevant to all three.
B. ShoiiLd the research components of ADAMHA be placed in NIH and the
service components placed elsewhere in HEW?
173
After much thought, I have come to the conclusion that the research and
service components should not be separated, although I am aware that there are
strong arguments for doing so. I would like to state what I believe to be the
arguments on both sides of this question, and then state why I believe ADAMHA
should not be broken up.
Arguments for separating service and research.
a) As I have already mentioned, various components of the research portfolio
do not seem to be equally effective in making discoveries that have a door-opening
or breakthrough property. In a bureaucratic research institute, administrators
argue for equal treatment. Thus bureaucratic features of the organization can
lead to an "equal" or "fair" distribution of funds, with the result that unproduc-
tive approaches are given too much support.
b) The presence of service components in the institute supplies even more non-
research people who will argue against giving needed funds to basic research.
c) The constituencies of service, as opposed to research, will have "too much"
influence on priority setting if both service and research are planned in the
same institute. In my opinion this has occurred within the last year, when
minority groups on the staff and in advisory groups asked that all research funds
be devoted to minority problems for several years. This can be seen as a political
effort to focus attention on the small number of minority investigators in the
country and on the seriousness of some minority-related problems in the mental
health delivery system. I believe that significant efforts should be made to
increase the number of minority investigators in all fields and that good research
on minority-related problems should be encouraged. But I do not believe either
of these should be done in a way that would interfere with the research designed
to solve those problems that led to the creation of NIMH. There is a danger that
particular constituencies, with very real grievances and a very real right to
participate in goal setting, will temporarily carry too much political weight.
Although a quota system was considered that required a fixed percentage of funds
be devoted to minority-related problems, I believe this plan has been shelved
and that other ways of paying attention to minority problems in a way that will
not divert funds from other important goals has been substituted.
\lh
It is also possible that, from time to time, concerns of citizens will be
conveyed to the Congress which will then mandate centers so that NIMH will be
required to support research in new areas without receiving new funds, either
for the research or for the administration of the research. When this happens,
it cannot help but reduce the funds available for other research. A recent
example is the creation of a rape center because of public concern over rape.
In my opinion, this type of event is not due to the presence of service activities.
It is due rather to the wide range of problems tackled by NIMH and to quite
legitimate concerns of citizens and quite legitimate political actions by Congress.
However, it is also due to a lack of understanding on the part of both citizens
and some Congressmen about the effects of mandating new research with adequate
funds .
d) If ADAMHA has both service and research functions, the choice of which
individuals sit on the NAMHC and other similar coimcils will reflect citizen
and service needs to too great an extent. I believe this argument carries
considerable weight. With the change in policy that led to half of the councils
being chosen from citizen and consximer groups, there has been a clear drop in
influence on the council by scientists.
Arguments for keeping research and service together in ADAMHA.
a) The major reason for keeping research and service together is that research
people have much to contribute to the planning of good service programs and vice
versa. The problems which create the need for research arise because our methods
of prevention and treatment are inadequate in service situations. I admit that
most service people are decidedly not research minded and seem surprisingly content
with prevention and treatment methods that are not now doing the job that needs to
be done. This fact argues for more rather than less interaction between the two
groups .
b) Researchers who are too far away from the service problems that create the
need for research lose interest in the original problem. They become concerned
in research for its own sake and do not pursue application that would make a
great impact on patient care .
175
c) The presence of service people in a research planning organization keeps a
needed emphasis on the multiple determinants of pathological behavior that require
some understanding of the mix in biological, psychological, and social approaches.
d) The citizen movements that are effective in providing funds for mental
health research, including basic research, are interested in both service and
research. I believe that the National Association for Mental Health could not
lobby as effectively for funds if research and service were separated.
76
Recommendations.
It is my opinion that the service and research functions should be kept
together for the reasons cited above. However, I suggest that the President's
Biomedical Research Panel consider ways of dealing with the problems that argue
for separation.
a. In the first place, something must be done to make the advisory
councils more influential and to put more research clout into them. I believe
that half of the people on the council should be scientists (not necessarily
in the mental health field) and that they should be chosen because they can
provide a useful overview to the directors and staff. The Panel could be very
helpful by explaining to Congress and administration leaders the value to an
institute of having a constructive critic on a council. But if the council is
to continue to approve grants, more coimcil members must have served on initial
review groups and must know good research from bad. If the council cannot be
given more research expertise, some alternative peer review system should be
developed.
b. The Panel should consider ways in which it can protect what I shall
call "core" research from what I shall call "needed so support" research. I
believe it should recommend an Institute on Social Problems that would assume
major responsibility for many of the real social problems that need investigation.
Thus, the only social problem research in NIMH, for instance, would be that which
has a direct bearing on the mentally ill and the mental health delivery system.
If this is not politically feasible, some other protection for basic and
disease-oriented research is needed.
Gardner C. Quarton, M.D.
Director, Mental Health Research Institute
The University of Michigan
77
NATIONAL ASSOCIATION OF LIFE SCIENCE INDUSTRIES
Introduction
The National Association of Life Science Industries, (NALSI)
is an association of for-profit, tax-paying business entities engaged in
life sciences activities which are affected by governmental policies and
actions. Most of the member companies perform research, or research services,
for the federal government, primarily, though not exclusively, for the
National Institutes of Health. A number of the companies also produce
health related products for the government and commercial market. NALSI
is a non-profit association incorporated under the laws of the District
of Columbia.
The member companies of NALSI represent over 75% of the total
life sciences firms performing research, or research services, for the National
Cancer Institute and constitute a substantial percent of the life sciences
companies doing business with NIH.
The member companies, collectively, represent a private capital
investment in life sciences facilities and equipment of about $60 million.
The 1974 level of government contracts with NALSI members amounted to about
25 million. The foregoing figures are exclusive of contract or sales volumes
of parent companies, such as: Litton Industries, EGG, Whittaker, Becton-
Dickinson, etc.
The NALSI Objective
NALSI favors equitable competition for government funding among
all resource sectors - the academic institutions, non-profit laboratories
and foundations, and the tax-paying business entities. NALSI believes that
there is a role for each and a need for each sector's resources, and that
discriminatory policies serve to encumber progress toward national health
objectives and add to the taxpayer's burden.
179
Credentials
The May 1, 1975 Congressional Record published the prepared remarks
of Mr. Benno Schmidt, Chairman of the National Cancer Advisory Board, which
was delivered by Mr. Javits. In his address, Mr. Schmidt gave three examples
of research sponsored by the NCI, thre results of which were considered most
noteworthy in the progress toward the understanding and treatment of cancer.
We do not believe that Mr. Schmidt sought examples of industry
contribution, or that, initially, he was aware that the examples given
derived from NCI sponsored research under contract with the private, life
science industry. But, that is the case.
NALSI member companies employ approximately 550 scientists
in addition to 2,700 technical, administrative and managerial personnel.
The scientific disciplines represented by NALSI members include, but are
not limited to, the following:
Analytical Chemistry
Agricultural Chemistry
Bacteriology
Biochemistry
Biology
Biophysics
Cell Biology
Chemistry
Electron Microscopy
Enzymology
Human Pathology
Industrial Health
Immunochemistry
Immunology
Medical Microbiology
Medicine
Medicinal Chemistry
Microbial Genetics
Microbiology
Molecular Biology
Organic Chemistry
Parasitology
Pharmaceutical Chemistry
Pharmacology
Pharmacy
Psychology
Physical Chemistry
Physics
Physiology
Radiation Biology
Radiological Physics
Synthetic Chemistry
Toxicology
Veterinary Medicine
Veterinary Pathology
Virology
Zoology
l8o
T he Problem
The general problem is that most NALSI companies are on a
gradually declining stay-alive contract renewal curve. The number of
new awards has dropped markedly in the past three years. The specific
problems include the following:
1. Where cost is a factor in proposal selection, the require-
ment that tax-paying companies' proposals must reflect the payment of taxes,
interest and other "unallowables" not present in proposals from academic
institutions does not represent true competition.
2. As a matter of HEW policy, "profit-makers" are ineligible
for grants. It isn't that business corporations are primarily interested
in grants, as such, (although as a matter of principle the policy is inequit-
able and discriminatory) but rather that the policy enables large blocks
of funds to be programmed away from competition. Academic and non-profit
institutions are eligible for both grants and contracts, and to the
extent that grant programs are funded at the expense of contracts, not
only is competition diminished and private investment discouraged, but
tax revenues are also reduced.
3. The "Peer Review" system, while offering many advantages,
is presently an imbalanced mechanism. At NIH, membership on the peer review
committees consists of about 1,700 scientists from academic and non-profit
institutions as compared with three scientific representatives from life
sciences industries. Although government program administrators have the
power de jure to approve or deny the recommendations of peer review committees
on contract awards, the fact that the committees' recommendations are rarely
not accepted, vests the peer review committees with substantial de facto
power; and the imbalance in membership from academic sources does not assure
an understanding of the capabilities of private industry.
181
4. The capital facilities' grant programs of various govern-
ment agencies, while important to pursuit of worthwhile research objectives,
compounds the inequity between the tax-paying and tax-supported sectors.
Capital facilities granted to academic and non-profit institutions are
expensed in a single grant. Thereafter, that facility is "free" to any
government agency. Moreover, the granting agency, having justified the
capital grant in the first instance, may f«l obliged to keep the facility
usefully occupied in order, theoretically, to amortize the government's
investment over a longer period of time. Each year, new capital grants are
made to tax-supported institutions. The FY'75 budget of NCI, for example,
contains $31.7 million for capital grant facilities. It, therefore,
becomes a vicious cycle: the more capital facilities granted by the
federal government, the greater the competitive disadvantage of the tax-
paying company. Carried to its logical extreme over a period of time,
the incentive for private investment in capital facilities could be
substantially undermined.
In brief, the objectives should be to level out inequities in
competition between the tax-paying and tax-supported institutions.
Recognition and Progress
NALSI has presented its concerns at virtually every appropriate
level of the Executive Branch and some significant actions are resulting.
For instance, the Director, National Cancer Institute, recently has promul-
gated instructions which separate the indirect cost portion of proposals
from the technical presentation. NALSI had pointed out, with examples,
that many peer review committee members, and some government directors, while
offering outstanding scientific qualifications, were not well versed in
accounting matters. As a result, industry proposals were sometimes given
low scores because "the overhead was too High", not appreciating that a high
182
overhead percentage rate might reflect modern automation and low direct labor,
thus offering efficient performance and lov/er total cost to the government.
In addition, it is in the indirect cost portion of a proposal that such items
as taxes, interest, EEO programs, etc., would appear. The Director has also
offered to cooperate in the development of statistics which more accurately
measure procurement trends and practices. —
At the direction of the Assistant Secretary for Health, HEW, an impor-
tant study is now underway , which will, perhaps for the first time, accumulate
data on cost differentials between successful and unsuccessful procurement
competitions. Analysis of a limited sample of actual procurements in which
awards were made on the "technical merits" revealed that the winning award also
happened to be the lowest cost proposal. NALSI inquired whether cost might
possibly be influencing technical evaluation. Thus, a larger, more
representative sample is required and should be available through this study.
Also at the Direction of the Assistant Secretary of Health, a study is
underway in PHS to consider the eligibility of tax-paying companies for
grants. This action is based on N/^LSI's contention that the practice is,
in most cases, the result of policy and not of law and has no foundation in
equity. Grants can be important in the retention of highly qualified scientists
in private companies and the bulding of scientific strength and experience in
selected program areas. No date for the completion of this study has been set.
Despite the sympathetic attention and action at the agency head
level, some of the basic issues are government-wide in character and are
beyond the authority of the individual department or agency to resolve in
the absence of specific policy direction of uniform application.
1
PHS/NIH Working Group studying "Competitive Cost Factors"
183
The Need for a Policy: A Role for the President's Biomedical Research Panel
The President's Biomedical Research Panel would appear to be in a
unique position to bring about the policy enunciation required.
NALSI recommends that the Panel recommend to the President
the development of a policy directive which would:
1. Recognize the life sciences industry as a national resource
in the government's health related research and research services
programs;
2. Provide mechanisms for assuring increased competition through
elimination of practice:; which discriminate against tax-paying
resources.
3. Recognize the difference between research costs to a government
agency in terms of its annual budget dollars and actual cost
to the government in terms of loss of tax revenues and loss
of private investment;
4. Rectify the present imbalance in the composition of the peer
review system.
5. Encourage investment of private capital in the government's
health research and research services programs.
The policy should provide for annual review and accountability mechan-
ism of progress consonant with the policy directive.
NALSI would be pleased to cooperate with the Panel, or the
designated department or agency, in the development of the foregoing policy
directives.
184
National Association of State Drug Abuse Program Coordinators
Suite 900 • 1612 K Street, N.W. ■ Washington, D. C. 20006 ■ (202) 659-7632
Rayburn F. Hess*
Joel A. Egerison, Minnesou STATEMENT OF RAYBURN F. HESSE
TO THE PRESIDENT'S BIOMEDICAL RESEARCH PANEL
Mankind has historically misused and abused a great and constantly-
changing variety of psychotropic substances to alter mood, relieve tension,
reduce anxiety, alleviate depression and to recreate. While medical and social
historians document some continuing patterns of misuse and abuse among certain
population groups, drug abuse, as a major social, political, medical and criminal
justice phenomenon has tended historically to be epidemic, cyclical and often the
result of subsequently identified stimuli, which were interrelated to specific
circumstance.
In the last half of this century, drug misuse and abuse has become more
permeating and pervasive; while the abuse of specific substances continues to
be episodic and cyclical, with major shifts in user typologies and patterns of
use, the overall trend, especially in Western civilizations, has been toward
widespread experimentation, misuse and abuse, with ever-larger population groups
becoming and remaining involved at increasing personal and monetary cost to soci-
ety. While major epidemics of addiction, as these would be popularly defined,
are isolated, there is today a major pandemic of drug misuse among Western nations,
with ever-increasing reporting of drug misuse and abuse among emerging nations
and Eastern bloc countries-.
The United States has experienced several previous outbreaks of drug
abuse in this century; most of the pre-1960 incidents were self-contained or
isolated to certain population groups, patterns of abuse, and drugs of preference.
The major post-war outbreak of heroin addiction in the United States
reached its peak levels in the late Sixties, with a significant involvement of
younger addicts, not limited to urban centers, emerging in the 1968-70 period.
Concurrently, although not absolutely related in terms of cause, or incidence
and prevalence of use, there was an upsurge in the use of non-narcotic drugs,
and, in 1970, clinicians and researchers were observing a pronounced phenomenon
of polydrug or multiple drug abuse.
Although there have been cyclical changes in absolute incidence and
prevalence, for example, the sturong downward trend observed in indicator data
relating to heroin addiction in 1973-74, the evidence today is that the nation
is again experiencing widespread increases in heroin addiction and non-narcotic
drug abuse, the spread of heroin use and addiction now involving many of the
nation's smaller cities, with an attendant shift towards consumption of the so-
called "brown" heroin from Mexico.
185
Thus, during the five-year lifespan of major Federal anti-drug abuse
efforts, which began with the passage of P.L. 91-513 in 1970, there have been
two major outbreaks of heroin addiction, and, despite some siiriilar cyclical
changes, a constantly rising curve in the incidence and prevalence of use of
other, non-narcotic drugs.
Truly concentrated, comprehensive Federal-state-local efforts in drug
abuse prevention are less than three years old, commencing with the passage of
P.L. 92-255 which was signed into law on March 21, 1972. Drug abuse in the
truly national (not just Federal) sense began with the conferring upon the Special
Action Office for Drug Abuse Prevention of the requisite authorities to plan and
to coordinate a national strategy, supported by coordinated efforts in treatment
initiation and expansion, program development, research, training, and planning,
the national strategy relying in major part upon the assvimption by single state
agencies of major responsibilities for planning, managing, and coordination.
The initial and continuing major Federal priority for this new national
effort was upon heroin addiction, and, this effort, combined with collateral
efforts in law enforcement, has been seen as effective in producing the downward
trends in 1973-74.
To plan a national strategy and to implement a truly national program,
SAODAP had to coordinate the activities of at least 19 different Federal agencies,
who shared portions of the total Federal expenditure for drug abuse prevention;
assist states in developing single state agencies and first year plans; plan and
initiate a major treatment expansion program; and analyze and evaluate our responses
to drug abuse in search of long-term solutions.
A principal reason, from the problem management perspective, why we are
again experiencing an outbreak of drug abuse is that the remedies applied were
essentially short-term in nature, and consisted largely of treatment and availa-
bility control measure focused on heroin. There are no proven mechanisms to pre-
vent the spread of drug abuse to new population groups, no nationally effective
plans for extending treatment to persons who do not seek treatment, no effective
or proven programs for primary prevention that would protect (or prevent) non-
users on a broad scale from entering the culture, no nationally demonstrated
effective rehabilitation programs that would sustain the treated, former user in
long-term social reintegration, and very little usable data on the various cause
and effect relationships that produce a drug epidemic or outbreak.
Only in the last 18 months have we begun the kind of critical examination
of treatment disciplines that will ultimately permit us to assign a patient or
client to that modality of treatment which experience dictates offers the high-
est probability of successful recovery and rehabilitation. We are only on the
threshhold of taking new initiatives in primary prevention, having learned through
experimentation, and trial and error, that the classical, education-oriented
approaches of the recent past will not contain the problem. We are only now
prepared to act upon the acquired knowledge that treatment without concentrated
rehabilitation merely responds to the most manifest of a drug abuser's problems.
We have yet to provide positive, acceptable alternatives to those persons who
recreate with drugs. New, more innovative approaches to the delivery of services
186
in rural areas, in treatment of polydrug abusers, in research that provides the
data for decisionmaking about clients in treatment and for overall management of
the problem, in information systems that v;ill enable us to be cost-effective,
and in new programmatic efforts that capture and involve the whole of the soci-
etal resource in total rehabilitation are just coming off the drawing boards of
system managers.
We are only now beginning the assessments that will isolate causal
factors in a manner that permits resolution through programming.
There are those who would believe that the problem has been stabilized,
and, believe that the situation is sufficiently manageable to permit a reduction
in force effort and resource level and the assignment of continuing responsibility
to a fourth-level administrative agency with HEW — the National Institute on
Drug Abuse.
Such judgments seem to assume that drug abuse has responded favorably
to some kind of five-year plan, as though the issues confronted in 1970 and 1972
were such that two years of initial Federal program support, augmented by three
years of concentrated national effort were sufficient to identify all of the
deep-rooted causes, to eradicate from within society those factors which give
support to drug abuse, to devise and extend to all social casualties finally-
effective treatment and rehabilitation measures, and to develop and implement
fail-safe prevention mechanisms which would prevent another outbreak of drug
abuse.
We have not achieved these objectives; most assuredly, the drug abuse
practitioner and the state managers do not believe we have acquired or achieved
the requisite levels of competence.
Ironically, the drug abuse industry has had to respond to demands from
Presidents, the Congress, oversight agencies, and critics for more sophisticated
approaches, for greater knowledge of process, for more effective application of
resources, and for more outstanding achievement that any comparable effort in
the social and health fields in memory.
Given relative factors of problem dimension, resource availability,
historical expertise, and time, the evidence is that the drug abuse industry
has gone fiirther with process development and problem resolution in these five
years than any of those comparable social and health efforts. But, we need. to
continue, at this same high level, to learn and to apply the lessons of those
experiments and more precise authorizations, more specific priorities, a more
comprehensive national (not just Federal) strategy, and, we need coordination
and cooperation at the highest levels of the Federal government.
The issue is not a simple matter of dollars. The issue is whether the
host of decisionmakers — the President, the Congress, SAODAP, 0MB, HEW, NIDA,
and the states — will make the collective commitment to develop the requisite
expertise and resources and programs to resolve this problem and prevent its
recurrence .
187
The truth ia that there is no such universal as the heroin addict, or
drug abuser. Instead, there are a variety of individuals who use drugs, licit
and illicit, narcotic and non-narcotic. There are persons who are infrequent
users, habitual users, dependent users, and addicted users. There are persons
who are dysfunctional without the use of drugs and persons who cope and become
relatively more functional with the application of drugs. There are persons
who use drugs for different reasons and with different effects, individuals who
are of varying ages and ethnic and economic backgrounds, who have differing
social and psychological characteristics, persons who are at different stages
of involvement in the drug abuse process, and persons who are therefore at dif-
ferent states of readiness to receive and profit by our help.
Typologies of users, motivations for use, drugs of preference, the extent
of use and abuse, the effects of the various drugs, the responses to treatment,
and the willingness to accept treatment vary from user to user, community to
community, and nation to nation, and, these factors can be altered by mood, set-
ting, environment, different effects, dosage and social attitude.
We must respond to the human needs of persons who use drugs to escape,
but, we must also respond to persons who use drugs to cope and adapt, and, we
must meet the needs of that larger body of persons who use drugs to recreate —
and ask ourselves why so many persons seek such an alternative in an advanced
society.
Above all, if we are ever to contain drug abuse and prevent drug abuse,
we must identify within our midst that larger group of individuals who are vul-
nerable to drug use in a drug-taking society — the non-users who are at risk —
and assist them through meaningful alternatives to cope, adapt, and even recreate
without the need for consuming drugs to create the synthetic achievement of these
pursuits.
We must, as our experience dictates, shift our concentration to the user's
life style and to the functional causes of drug abuse, rather than focus upon
the elimination of the use of any one drug.
In mythology, the four horsemen are famine, death, pestilence, and war.
If the analogy is accurate that drug abuse is a cursed agressor threatening our
social order, then the new companions are poverty, alienation, and fear — the
fear of being unsuccessful, the fear of not being able to cope, the fear of fail-
ure, the fear of not being able to compete, the fear that breeds insecurity and
prompts escape, the fear of not being able to adjust, the fear that breeds upon
behavioral problems that individuals cannot overcome without help.
Similarly, there is economic poverty, but there is also the poverty of
opportunity, the impoverishment of minds, the impoverishment of one's health,
and the poverty of frustration. And, if drug abuse rides as a companion with
the alienation born of racial discrimination, it is surely as one with the aliena-
tion that comes of being in that limbo between adolescence and adulthood, the
alienation of social and parentalre jection, and the lonely alienation of the
underachiever in a society that stresses excellence.
188
If it is true that we have only begun to probe the causal effects of
drug abuse, it is equally true that the course of our investigation is known
and ca^; be documented by the early evidence, i.e., drug abuse is related to,
contributes to and derives from corollary social and health problems, including
but not limited to a spreading phenomenon of behavioral health problems, as well
as the social disorders of unemployment, lack of opportunity, lack of skills
training, lack of education, alienation of the young, alienation of the segre-
gated and those against whom we discriminate.
Thus, as the National Association's survey and analysis for NIDA demon-
strated, drug abuse cannot be eradicated solely by the programs of SAODAP and
NIDA, but will need the cooperative assistance of agencies such as HUD, Model
Cities, Labor's manpower and vocational programs, other health agencies including
NIMH, and the whole of our social service resource. This kind of massive effort
would need the kind of high level cooperation that is at the heart of our pro-
posal, both when we address the need for an Office of Drug Abuse Prevention Policy
and the new mechanisms for Federal-state cooperation.
A major deterrent, perhaps the primary deterrent, to an effective solution
to the problem of drug abuse has been and remains our failure as a society to
determine, declare and pursue an accepted drug abuse policy. The ultimate truth
we must recognize is that neither society, nor government, nor the professions
have made up their collective minds as to what they truly want done about drug
abuse. Our failure to address the problem in the whole of its societal context
has created confusion, contradiction, and has frustrated our best efforts.
Social policy is most often determined by politicians as a response to
political need or political circumstance, and, not as the natural product of
social, psychological, and scientific investigation and examination of the health
needs or problems of society. Policy therefore is m.ost often not stated but is
found inherent in practice; too often, however, prevailing practices dictate
policy.
Drug abuse policy, then, is an integral part of general social policy —
urban planning, education, working conditions, leisure aspects, public health,
economic strategy, etc. — and cannot be isolated from these broader issues. In
a societal context, we have an infinite number of social casualties, some of whom
use drugs.
Social policy must not be dominated by criminal justice policy. No other
social or health problem (or its attendant programs) has been as dominated by or
impacted upon by criminal justice policy as has drug abuse. The fear today, par-
ticularly with diminishing budgets and the lowering of priorities, is that crimi-
nal justice approaches will again assume dominance — a leverage which SAODAP in
three years of effort was finally able to put into balance with drug abuse preven-
tion.
There is a major concern that time is running out on the drug abuse pre-
vention industry, that an increasingly frustrated (or politically satisfied)
government and an anxious society will resort to virtually unlimited application
of the law and law enforcement — unless treatment and prevention are made more
effective and more responsive to an established policy and given the necessary
priority.
The National Association proposes a system for developing not only a more
comprehensive, long-term strategy but also for the development of a broad-based
social policy on drug abuse prevention.
This proposal is fully cognizant of the several major needs of the field.
Vie need to provide effective treatment for the narcotic addict and the
non-narcotic drug abuser — but not just treatment but treatment and rehabilita-
tion that assures maximum potential for social reintegration — and not just treat-
ment and rehabilitation but treatment and rehabilitation as part of a total social
mechanism that supports a system of primary, secondary and tertiary prevention.
In direct contrast to the opinions of those who believe we can now lapse
into ordinary, day-to-day management of a system, i.e., no further exploration is
necessary, the National Association believes there are a host of related needs
that must be met to develop and support this system of primary, secondary, and
tertiary prevention.
In addition to the fields of exploration cited earlier, we need, as a
matter of highest priority, to provide high-caliber training for personnel — for
new paraprofessionals and professionals entering the field, and, for the thousands
of program workers currently engaged in the field — this training to be an inte-
gral part of the overall effort to upgrade program quality, an effort that simul-
taneously involves program licensure and accreditation, evaluation, and personnel
certification and credentialling.
We need to ask such questions as: Does our internal program really pre-
pare the client for a work experience? What supportive services must we provide
to augment manpower programs?
We need to draw more indelibly that narrow line between that drug educa-
tion which properly acquaints the user and potential user of the hazards of drug
abuse and that drug education which merely creates a morbid curiosity to experi-
ment.
We need to rethink our approaches to community and in-school education.
Despite the education efforts of recent years, the ignorance about drugs is appal-
ling .
We need special studies into the specific problems related to polydrug
abuse .
We need to attract and involve more scientific, academic, medical and
other institutional resources.
We need to study acute drug reactions among youth, with important concen-
tration on post-treatment activities.
We need to analyze the relationship of marihuana use and other initial
drug use and subsequent drug abuse, looking not only at transitional factors,
but also at the phenomenon of association, especially among multiple drug abusers.
190
We must expand our knowledge of onset factors, particularly among young
people, with special emphasis upon attitudinal studies.
We need a program that attacks the many facets of drug abuse as it
specifically related to business and industry. There is a need to enlist
industry in a total effort to train and employ the rehabilitant , else we risk
continuing recidivism. But, there is even a greater need, which is to examine
the whole of our vocational rehabilitation effort, with special emphasis upon
marketable job skills.
There is a need to question our whole approach to institutional settings.
We need more effective programs oriented to youthful abusers of non-
narcotic drugs.
We need alternative dispositions having the full, concerted support of
the total spectrum of the criminal justice system, which can be a measurable
influence in the reintegration into society of individuals who, but for the lack
of such alternatives, would possibly have never become involved in a life style
of crime.
We need, finally to conduct the kinds of analysis of drug abusing per-
sonalities and typologies of behavior which will enable us to identify vulnerable
groups within our population, and, we need to construct and employ those inter-
vention-alternatives-education-guidance programs which will interdict the pro-
gressive path of drug abuse.
THE NATIONAL ASSOCIATION POSITION
The major purposes and effects of the National Association's proposal are:
• To establish a new, higher priority for drug abuse prevention, con-
sistent with today's expanding problem, and to establish commensurate
priorities for primary and secondary prevention, criminal justice
diversion programs, alternatives programs, and drugs-alcohol programs,
with appropriate reflection of new data indicating a resurgence of
drug use and abuse.
• The creation within the Executive Office of the President of an
Office for Drug Abuse Prevention Policy, a policymaking and coordi-
nating office which would be the successor to the Special Action
Office; an office which would have no direct program authority but
which would be designed to insure the continuing coordination of the
Federal-state-local effort and to promote certain priorities and
special impact programs.
191
The establishment of the National Institute on Drug Abusa as the
lead program agency, assigning to NIDA the majority of the program
responsibilities previously assigned to SAODAP and/or the Secretary,
HEW.
To define and present a specific list of policy objectives for the
Office, and, ensure that program agencies have the specific authori-
zations needed to initiate recommended action programs.
The setting of critical program priorities for the Office and
Federal agencies, labelled Special Impact Programs; this section
would permit the Congress to establish Federal priorities for all
programming, including the expenditure of special purpose funds
appropriated for the Office.
To insure a continuity of program effort across the broad spectrum
of drug abuse prevention activities by assigning specific funding
authorizations to particular categories of program effort, e.g.,
rural service delivery, state training programs, primary and
secondary prevention, combined drug and alcohol service programs,
and criminal justice diversion.
The restructuring of the Federal Strategy Council, the National
Advisory Council for Drug Abuse Prevention and the President's National
Advisory Council, and the creation of a Federal Drug Council, this
restructuring designed to insure appropriate policy advice from the
various elements of the drug abuse industry; to insure coordination
at the departmental, administration, agency and institute levels;
and to insure that the Federal strategy and the national strategy
are consistent with and are a part of the Federal plan for each
fiscal year.
Revision of current Federal-state planning and coordinating proce-
dures, to insure that state plans are current with Federal fiscal
years; to take advantage of new opportunities inherent in changing
the Federal budget process for planning and funding by the Federal
government; to permit a more precise targeting of resources to
achieve specific plan objectives, and, to give viability to the
Federal-state-local planning process.
The enhancement of the duties and responsibilities of the states.
The authorization of $394 million for directed drug abuse prevention
programming including authorizations for ODAPP, NIDA, NIMH and
ADAMHA.
There is ample evidence that the new initiative of the last three years
has been productive, overall; there are equally compelling data that prove the
problem continues to grow and remains beyond the frontier of true containment
or control.
192
Just as it is essential that the Congress recognize the dimensions of
this problem, it is critical to the action steps proposed that Congress also
recognize the continuing need for a high-level coordinating authority for policy
and for a lead agency for program.
There are several options: ODAPP, SAODAP extended, 0^'IB, the Domestic
Council — each could coordinate the Federal and national efforts to different
degrees and with different effects. But, to be truly effective, the Federal
coordinating authority must be responsive to and available to its drug abuse
constituency, a fatal defect (among others) in the makeup and purpose of the
Domestic Council and 0MB. The conditions which compelled a SAODAP to come into
existence are still present, with one major exception. Today, unlike 1972,
there is a major agency (NIDA) which has been specifically developed to adminis-
ter and monitor Federal programming, and ODAPP (SAO) should be relieved of that
responsibility.
It would be duplicative and counterproductive to have two major agencies
for programming. Thus, we believe ODAPP should concentrate its resources on
policy and coordination while NIDA focuses upon program development and imple'-
mentation.
We have subsumed in the foregoing an agreement that there will indeed be
a Federal coordinating authority at the Executive Office level. The fact is
that, even if SAO expires on June 30 and no new office is designated and estab-
lished, 0MB will assume major responsibilities for policy development and policy
coordination — with the same effect as having been designated the coordinating
authority — because that is the way the modern-day Executive Office is operated.
We have also subsumed in the foregoing an understanding that NIDA, a
fourth-level agency within HEW, cannot leverage the entire Federal programming
effort nor coordinate it.
The need for an ODAPP, or coordinating authority in the Executive Office,
is not predicated upon political desire nor even on the fact that such a presence
tends, of its own nature, to give a priority to the goals and purposes of the
Office.
The most compelling arguments for the ODAPP-NIDA configuration — and
for changing and/or redirecting certain policies and programs — find their
justification in our incidence and prevalence data and indicator data — if we
really examine that data for their total import.
Treatment demand is increasing at a rate of some 2,500 units per month;
heroin overdoses are increasing an average of 13.5 percent per quarterly period;
indicators are up for non-narcotic drug use; the drug abuse phenomenon is being
recorded with regularity in middle-size and smaller communities where drug depend-
ence, particularly heroin addiction, was heretofore uncommon; drug availability
is once again being taken for granted; and drug-related crime appears to be on
the increase.
193
The trea':jnent expansion programs of the SAODAP era achieved the point-
in-tim--; goal of providing treatiaent services to the majority of those persons
demanding such services, and, there is evidence that this provision of services
was beneficial.
But, both the successes and failures of these initiatives must be examined
in a certain perspective, i.e., their relativity to the drug abuse dynamic. Drug
abuse is cyclical, and evolutionary within its cycles. Yet, we have created no
permanent, well-researched, comprehensive systems to prevent a recurrence of drug
abuse. We have no established apparatus for embracing those persons who do not
seek treatment. We do not have programs or systems that are proven effective at
preventing initial drug abuse. We have a limited supply of prograjns that offer
assistance to marginal users or persons who are vulnerable to dysfunctional use
of drugs. And, we do not truly rehabilitate; we treat manifest symptoms.
However, that too is a time-specific perspective. The last three years
have also seen unprecedented efforts to instill quality controls in programming,
both in treatment and prevention; unparalleled efforts to train both professionals
and paraprofessionals in new techniques of treatment and rehabilitation; deter-
mined attempts to devise new methodologies for identifying vulnerable populations;
imaginative efforts to develop effective and acceptable alternatives to drug
abuse; and, through coordinated planning, extensive efforts to involve the whole
of the social service resource in the provision of assistance to the drug abusing
individual.
The challenge has been one of trying to match an imperfect system to an
imperfect problem that follows no format; mistakes have been made but some pro-
mised threshholds have been reached; the process has been proven.
That we did not find all of the answers we were seeking, or, craft all
of the solutions we needed in these three years is not the surprise. The surprise
is that, with evidence readily available that these gains — however small some
may be — were the product of coordinated policy and programming, there should
be any question about the merits of continuing.
This is not to say that this same evidence suggests conducting the national
strategy on precisely the course of the past; changes in policy and direction are
warranted — and proposed.
The essential thrust of this discussion finds corroboration in every sig-
nificant study of the problem of national administration of drug abuse program-
ming, including the Shafer Commission, Ash, and Prettyman studies.
We can also look to the analysis of state plans by the National Associa-
tion. The states, after exajnination of their drug abuse problems, did not simply
project "more drug abuse programs:" they proposed 34 distinct program modalities
in just primary and secondary prevention.
This approach, as envisioned by state and local governments, would require a
radical departure from traditional prevention approaches — as would their recom-
mendations in treatment or tertiary prevention programming — new, approaches that
I'iM
would emphasize values clarification over rigid moral codes, behavioral education
over cognitive information programs, personal approaches and initiatives over
mass indoctrinations, personal achievements and coping over class dynamics, and
total support for the individual over propaganda for the masses.
A program of the scope state governments believe is necessary would be
oriented to innovative approaches involving the whole of the societal resource,
and, it would require the cooperative participation of NIDA, the Office of Educa-
tion, DEA, LEAA, the Department of Labor, and the Model Cities progrJim.
Such a program, even one severely limited in terms of funding and scope,
that took the necessary (read comprehensive) approach, would have to be carefully
orchestrated — and that means we need an ODAPP .
It is also significant to note that the President's budget would appropri-
ate a total of $443.8 million for all drug abuse prevention activities, including
nondiscretionary funds; that 51.1% of these funds would be spent by 14 different
agencies other than NIDA,- and that the budget proposes no scheme for coordinating
these expenditures of funds or for coordinating Federal policy affecting these
agencies and their programs.
There are those who would say that it is equally important that we do
not allow the system to disintegrate. There are two sides to this issue. On
the one hand, we cannot afford again the petty factionalism, rivalries, failures
of communication, etc., that plagued Federal efforts — and the efforts of others
to cooperate with Washington — before SAODAP.
On the other hand, we need to protect and preseirve and enhance the gains.
We need look only at the criminal justice field — and at the programs throughout
the country made possible by interaction involving SAO, LEAA, NIDA, and DEA — to
see the benefits of coordinated policy and program — benefits measurable in terms
of young people now in treatment who otherwise would be in jail.
At the present time, SAODAP is self-destructing — and a price is being
paid.
On February 7, the Department of Labor's Wage and Hour Division's new
regulations requiring the payment of the minimum wage to patient workers in drug
abuse programs (among others) became effective. The initial deadline for filing
certificates of exception was March 9, which was then extended to April 1. The
National Association has formally appealed, asking that the deadline be extended
to August 1. This provision could cost drug abuse programs as much as $5 million
in FY 75. Yet, no notice was given to programs by NIDA. When the states con-
tacted NIDA officials, they seemed unaware of the new regulations. Our requests
for an advisory opinion have yet to be answered.
Similarly, drug abuse and alcoholism programs are being impacted by a
variety of health legislation emanating from the Congress. Although the compre-
hensive health policy and resource development act has been law since December,
we do not yet have an answer from NIDA as to whether drug abuse, which is not
mentioned in the legislation, is included, nor do we have advisory guidelines on
how new Health Service Agency planning will impact our current planning process.
195
Our purpose is not to cast blame upon NIDA or find fault. These and
other examples of Federal interagency activity impacting upon the drug abuse
field suggest strongly that NIDA is neither constituted nor situated to act
in behalf of the drug field at the upper levels of government. And, clearly,
there is need to protect this new young science and advance its causes at those
levels; there seems to be a progression of new legislation and guidelines that
affect us, with precious little or no input from the field.
In sum, the conditions which created SAODAP exist today, with all of
their attendant requirements for coordination and cooperation at the Federal,
state and local level.
In December, the Board of Directors of the National Association, having
determined by resolution to recommend the creation of the Office of Drug Abuse
Prevention Policy, asked the Special Office for both its reactions and for its
own rationale for the publicly-announced SAODAP recommendation for the creation
of a similar Office of Drug Policy.
The following statements are excerpted from that response.
"Since March 1972 some of the significant achievements of this
Office are:
Federal treatment capacity has been expanded from 16,000 to
128,000 slots;
A major restructuring of the Federal Government's response to
drug abuse has occurred — the approach has moved from an exclu-
sively law enforcement response to an increased law enforcement
effort balanced by a newly created treatment effort;
Communication and coordination have been established between the
criminal justice system and the health care delivery systems at
the Federal and state levels.
"Many other significant improvements have been achieved by the
Special Action Office in its short existence. However, the criti-
cal point is that despite these accomplishments, much remains to
be done.
"The drug abuse problem is not like other problems; it is much
more dynamic and the government ' s appropriate long-term role has
not been fully determined. At this time, the Federal drug abuse
response is not a routine, on-going function suited for manage-
ment through traditional and well-defined operations. Instead,
it is determined by a series of complex issues, and stimulated by
a high degree of unabated public concern compared with other social
and health problems.
196
"The drug abuse situation in the United States fluctuates
rapidly and requires high level, sophisticated attention. The
heroin problem cannot be ignored; once thought to be decreasing,
it now appears to be on the rise, being fed by an influx of
Mexican heroin and further threatened by resumption of opium
production in Turkey. These disturbing trends have been accom-
panied by an increase in the purity of heroin distributed in
the wholesale market, an increased supply of heroin on the
street, and increased demand for heroin addiction treatment.
"Paralleling these activities has been a significant increase
in FBI reported income -producing crime in almost every state.
National crime rates and heroin rates turned down in 1972 for
the first time, after a decade of sharp increases. The third
quarter of 1973 saw the end of these favorable trends. Rates
of both crime and heroin use are now rising.
"The drug abuse problem and the demand for drug abuse treatment
are not limited to the heroin addiction problem. The abuse of
other drugs has also led to a need for treatment.
"The drug abuse problem is exceptionally broad in scope, affecting
many agencies and programs. For example, drug abuse contributes
to increased adult crime and juvenile delinquency, increased
police and criminal justice costs, in addition to further burdening
welfare, unemployment, and medical and mental health treatment
services.
"The social costs of drug abuse in the United States are conserva-
tively estimated at $10 billion.
"The interagency diffusion of the drug abuse prevention function
must also be considered. Whereas the law enforcement function is
centralized under the Drug Enforcement Administration, the treat-
ment and prevention effort functions exist among several parts of
the Department of Health, Education and Welfeire; the Departments
of Defense and Labor; the Veterans Administration; and other agen-
cies. This necessary diffusion precludes comparable consolidation
on the treatment and prevention side. If the Special Action Office
is not continued, the prevention function would have only the fourth
level National Institute on Drug Abuse within HEW to attempt to co-
ordinate the vast effort.
"While popular concern about drug abuse has remained high, public
fear has in fact declined in the past three years, partly due to the
impact and successes of the Special Action Office. In effect, the
problem has been put in perspective by a balanced approach between
treatment and law enforcement. Nonetheless, drug abuse is a poten-
tially explosive issue. Without a sustained interest in its treat-
ment and control, the situation will deteriorate rapidly.
197
"Although much has been accomplished in the last three years, many
important issues are not resolved. Major remaining tasks include:
1) the allocation of resources cimong various claimants in the
treatment and prevention area; 2) closely monitoring the increase
in heroin use at a time when the Federal treatment capacity has
been exhausted; 3) the coordination and assignment of appropriate
roles to various agencies in drug abuse prevention activities;
4) continued high level coordination between law enforcement and
treatment functions; 5) the Federal Goverrjnent ' s response to the
marihuana problem; 6) and the development of an international health
initiative to assist other countries in becoming aware of and respon-
ding to their drug problems.
"Although the heroin epidemic of 1970-71 has been contained, more
complete data show that a new and serious situation has evolved.
Reduction of Executive Office level attention reduces the ability
to impact upon the United States' drug abuse problem. Given the
data available from all sources on the current status of drug abuse
in the United States, and the growing social cost of drug abuse in
the nation, a weakening of present emphasis and actions appears
unwise.
"There is a clear requirement to continue coordination among the
Federal departments and agencies to resolve complex issues and
direct the Federal response to unmet needs. The Special Action
Office is an established organization fully equipped to deal with
these issues. Its forthcoming expiration dictates speed in selecting
an option for future coordination of the Federal drug abuse program.
"The current drug abuse situation, unfinished business, and the
diffuse structure of the Federal drug abuse prevention program re-
quire strong leadership. Objective analysis of the options advances
a compelling argument that the preferred action is to continue drug
abuse coordination through an Office of Drug Policy within the
Executive Office of the President."
198
NATIONAL COUNCIL OF CHAIRMEN OF GRADUATE DEPARTMENTS
OF PSYCHOLOGY
To: Tlie President's Biomedical Research Panel
From: Giairmen of Graduate Psydiology Departrnents
As Giairmen of psychology v/e might be thought to have a rather
different perspective on the problems of biomedical research than the
previous ^^^itnesses before tliis panel. It would not, for example, be
particularly enlightening for you to speak to our deans since we are
primarily situated in literary colleges. Our faculties are relatively
less involved in providing clinical services although a great many are
so involved. A large part of our mission, at least in the opinion of our
deans, is to provide essential parts of a liberal education to our
undergraduate students.
At the sam.e time almost all of the scholarly research of psychologists
is directly relevant to biomedical problems. Little need be said here
concerning the role of the clinical psychologist in the healtii professions
or the importance of a sound scientific training in filling that role.
^\hat may not be obvious are the contributions of the other fields of
psychology to the biomedical endeavor.
For exaiTple, it is well knoun that there is a neurological basis
for aphasia and similar disorders. Perhaps in some of these there has
been insufficient attention paid to specific aspects of memory and cognition.
For example, some patients have great difficulty in remembering anything
which happened recently, others suffer loss of m.aterial learned long ago,
and still others can rem.smber in one sense both recent and past events
but cannot quite get them to the surface- -the tip-of-the-tongue phenomenon.
Since psychologists working in academic settings have for some time been
engaged in intensive study of various aspects of long- and short-term
memorv-, and problems both of encoding tlie material and its later retrieval
in research en these disorders, it seems reasonable to involve tliose
investigators in the stud/ of ashasia. At this point it might also be useful
199
to mention that these psydiologists have a great deal of information about
memory in normal people as well as people with disorders, and that they have
developed techniques of measuring mem.or/ losses which may not havs been
exploited by other biomedical workers.
A second illustrative example has to do ulth certain problems of
vision. It has always been assumed that in the absence of visual stimulation
or a stimulus for accommodation, the eye is focused at optical infinit)'.
However, recent evidence from an academic psychology laboratory strongly
suggests that this is not always true, and that instead tlie focus is much
closer. This finding has a number of important implications for immiediate
practical problems. One of these is that when driving at night one's eyes
are likely to be focused not at optical infinity but at, say, one meter. This,
of course, can cause serious problems ^-.hen driving an automobile, and
these can be alle^'/iated by m.eans of suitable lens in eye glasses. Another
is a problem which \>rill be familiar to many members of this panel because
it involves the design of microscopes, because again it has been thought
that when using a microscope, one's eyes are focused at optical infinity.
As a final example one of our faculty members, an organizational
psychologist, has carried out a long-term research program on tiie organization
of hospital nursing services. Although the enphasis here is not biological, no
one who has spent any time in a ward will deny the value of a well organized,
high morale nursing system in helping people get well.
Periiaps it is unnecessary to belabor the point that psychological
research is and has been an inportant part of the biomedical research effort
of science, since your invitation is evidence of your awareness.
Issues
The National Institutes of Health, the Alcohol, Drug Abuse, and
Mental Health Administration and their ancestral organizations ha\'e been
200
the principal goveraT.sntSLl supporters -of psychological research over the
past t^venty or so years. V.'e feel that the systems developed for this support
have worked well and that the country can be proud- of tJie resulting advances
in biomedical science. At the same tir.e we agree that the program now needs
a general review in light of changes in the environment in which we work.
We agree there is a linit to the amount of resources which should be put into the
biomedical research effort but do not believe that limit has been approached;
nevertlieless we are now severely constrained and will have to make choices.
Pe er Review
We believe strongly in tl\e peer review system. Our belief is based
on our conviction that scientific merit should be the overriding criterion
for SL^port and that peers are tl^e only feasible grotp to evaluate scientific
merit. We recogniie the criticisms that peer review could undervalue innovative
research, discriminate against new and unknown researchers, and even encourage
unholy help-one-another alliances, but we do not believe tliat has happened
to any large extent. If these are or become real problems, solutions shoiHd
be found short of turning the same decisions over to non-peers.
Research Training Grants
Being department chairmen, we are understandably fond of training
grants. Speaking principally of predoctoral research training grants, ive
feel they have shown themselves to be efficient devices to provide high
quality research training to the most qualified students. Stipends at the
current levels are adequate to allow training directors to recruit trainees
on the basis of tlieir scientific talent rather than their ability to support
themselves. Trainees can at the same time choose programs maximally congruent
with their career goals. Training grants assure the existence of a coherent
pixjgram and perhaps most inportant a cohort of trainees to help train one
201
another. Institutionally the training grant provides support: secretaries,
research facilities, offices at precisely the level they do the most good, at
the program level.
Individual research fellowships have their place, but suffer a
number of disadvantages relative to traineeships . The associated institutional
sijpport enters the university at an inappropriate level, such as the graduate
school or the department level where its benefits may not filter down
to the students' program. The fellow in effect awards the institutional
support to the university. This means the award may be made \>d.thout the
detailed understanding of programs available to the awarding agency, and
without the benefit of concentration of effort provided by the training grant
mechanism,
Sipport of research training through a loan system as cpposed to
fellowships or traineeships is inequitable and based on an unrealistic
assessment of the economic condition of the research scientist. On
strictly economic grounds the choice of a research career is not a good
choice for the sort of highly qualified biom.edical researchers we need.
Neither can we assume that these people are -necessarily products of affluent
families .
Loan systems also have the failing that they make no provision
for institutional support.
Research training through research grants is valuable but faulty
as a principal mechanism. The research investigator must keep his research
objectives at the top of his priorities and these will often not coincide
with those of his research assistants. For example, the orderly rotation
of students through different research laboratories is sinple in a training
grant program but costly on a research budget.
We feel that researcli productivity of a faculty is an important
criterion for the awarding of training grants and that criterion is typically
202
used. V/e also value the opinions of oar colleagues on national review
panels who choose fellows. Perhaps their opinions could be better utilised
by for.variing them to training directors; perhaps hot. In any case we
feel the research training grant should be continued and strengthened.
Funds available should determine the number of programs supported, not
their existence.
Researcli Grants and Contracts
We feel the procedures for ffi>farding research grants and contracts
have worked surprisingly well. One can easily conjure up failings of
the peer review system which would be possible, but we don't think they
happen often. There are of course administrative snarls and sometimes
grant proposals and final reports seem to take up an inordinate amount
of a scientist's time but we see no very good alternative.
The major issue here is how to recapture the relatively stable
environment in which the progran worked in the 60 's. Disruption due
to violent clianges in the direction of government policy and th.e con-
sequent changes in funding levels are inimical to good research. Projects
chosen to fit a grant period are not necessarily the best research, indeed
not even likely to be the best research. We have no advice to offer
on what the optimal funding cycle, or policy cycle, should be. It
is certain that from our point of view, longer is better.
One promising possibility for introducing some essential stability
in the research program would be to move most if not all research, grants
into a fonvard- funding system. That is, -congressional appropriations in
1976-77 should be for support of grants awarded in 1977-78. Fonvard
funding could be a major elem.ent in the stabilization of the grants process.
This would enable much more orderly staff operations and the review of
scientific merit can be relieved of any major concern with amount of appropriation
203
and budget.
This is not intended to escape appropriate congressional inquiiy into
and supervision of fiscal policy, grants managenent and effects of
expenditures. The fonvard funding principle would merely anticipate
such an overview rather than lea-ve it to hindsight.
Finally, concerning targeted research. There is little question
but that targeted researdi is not the best research from a scientific
point of view. Societal needs often override this consideration, but
it is always important to balance the short-term societal gains against
the scientific loss.
Other ProCTrams
We have had little contact \irLth. the General Research Support
grants except through conversations ;vith our colleagues in medical
school. Ivhile it is clear that such grants provide flexibility for
the medical school dean and can be very effectively used we understand
as administrators the conflict that can arise between the immediate
needs of the faculty and the long-term interests of biomedical research.
Similar problems on a smaller scale arise for training grant directors
and other administrators of "block" grants.
Professor Merrill E. Noble
Professor J. E. Keith Smith
Professor Joseph Speisman
lOk
7/8/75
TESTIMONY OF THE NATIONAL COUNCIL ON ALCOHOLISM TO THE PRESIDENT'S
BIOMEDICAL RESEARCH PANEL
The National Council on Alcoholism is a private, voluntary, health
organization devoted to creating further understanding and inter-
vention in this country for the control and treatment, and eventually
the cure of alcoholism. As such, it is the ombudsman for the patient
with alcoholism.
In this role we have been following closely the condition of
the country in regard to alcoholism, and the efforts made to
understand and combat it. Whereas we find that there is a greater
understanding about alcoholism in this country today, there still
remains a long way to go - and the significance and extent of the
problems cannot be underestimated.
The estimate made some 5 years ago that there are nine million
alcoholics in this country has not been revised although we know that
sales of alcoholic beverages have increased considerably and the
population has also increased, although not to the same extent. We
note that increased alcoholism among youths between 12 and 20 years of
age has alarmed many; and an increased proportion of women and older people
are involved S' Any currently proposed social method of control
of this problem by changing of the country's mores, such as the means
advised by the NIAAA for the Council of Education of the States appears
to be difficult of accomplishment, unsure of effectiveness, and it will
be long until any effect will be noted on the alcoholic population.
205
Testimony of the National Council on Alcoholism to the President's Biomeijical
Research Panel
A much reiterated statement by the director of the NIAAA has been
that we cannot solve a problem by dealing with the victims alone.
However, it is these victims who are the primary targets of the meaning
of the legislation in Congress establishing the NIAAA. This public
health problem requires solutions. The alarming nature of the
public health problem is underscored by the fact that in the last
twenty years deaths from cirrhosis of the liver, primarily caused
by alcoholism, have increased 63. 17= while deaths from heart disease
(3)
have decreased 15%, and those of cancer have remained steady. This
trend has continued this year and I quote the New York Times of
July 1, 1975: (4)
(This Year)
"Death rates from cirrhosis of the liver rose 17o while death
rates from suicide and homicide rose somewhat more sharply. . .
'alcohol, drugs and violence are the great killers of young
black males."
The strong connection between excessive doses of alcohol and violence
has been insufficiently emphasized recently, but the figures are
(5)
impressive for connection of alcoholism and child abuse, rape and
(6) (7) (8)
sexual molestation of children, as well as for murder, and suicide.
There is no question but that alcoholism is a phase of the interaction
of a psychoactive drug, ethanol, on the body and brain of man.
This interaction had negligible exploration by modern investigative
tools until eight years ago when the provision of money in the federal
government has spurred increased research. The investigations made
Testimony of the National Council on Alcoholism to the President's Biomedical
Research Panel
have produced major advances in our knowledge but these have only pointed
up the gaps which still remain - gaps that promise when filled to advance
the treatment and prevention of the morbidity axi mortality of the disease.
Of the major advances, one of the most striking has been the production
in baboons of cirrhosis ot the liver: baboons who were given a fully
(9)
nutritious diet and 507o of their calories as alcohol. These findings
overturn the long held belief that alcohol itself had no relationship
(10)
to cirrhosis. They also fit with the data of Lelbach, who demonstrated
by historical means that large quantities of alcohol were taken over long
periods of time by humans who developed cirrhosis. Further investigations
of the metabolism of alcohol, for instance in its effect on producing
enzymes used in synthesizing collagen (hydroxyproline synthetase)
could lead to measures that will prevent the development of cirrhosis -
the single disease entity which death rates show us to be unable at
present to control.
Another area in which alcoholism research has been productive has been
in studying its effects on the brain. Significant in this is the
demonstration that chronic tolerance or adaptive cell metabolism is
present - allowing the adapted individual to imbibe pharmacological
doses of alcohol instead of physiological ones. This profoundly
important quality - of needing more drug to produce the same effect
is what permits the individual to imbibe the quantities necessary
(12)
to produce the late physical consequences of the disease.
207
Testimony of the National Council on AlcoholisTn to the President's Biomedical
Research Panel
A third area is in the genetics of alcoholism - there is a strong
familial association in the incidence of alcoholism. This has been
clearly associated with inheritance rather than environment in several
well-performed studies using different methods. Thus, these studies
CI 3')
cry out for further definition and elucidation of mechanism. ^ '
(14)
A fourth area is that of the effects of alcohol on the fetus. This
has been demonstrated to produce a series of physical effects,
including effects on the brain; and is claimed to represent the
third largest cause of congenital malformations of the brain.
Understanding the mechanism by which alcohol causes its effect on
the brain, how this effect is changed by the development of tolerance,
and the emergence of pharmacological rather than physiological effects
on body, brain and behavior are certainly urgent priorities in the
health needs of the nation. Even before such final breakthroughs are
attained, the emergence of a mechanism for identifying people with
high susceptibility to alcoholism is a potential field of endeavor.
The National Council on Alcoholism has made itself familiar with
ongoing work in this field by a series of yearly conferences which
have brought together scientists working on the various aspects of it.
It has also, during the past 2 years, been able through a private
donation to award grants in biomedical research. Through this mechanism,
it has become even more apparent that there exist a large number of
competent investigators in the field who could profitably be put to
208
Testimony of the National Council on Alcoholism to the President's Bioniedical
Research Panel
work to answer the urgent questions now unanswered. Twenty- two research
proposals were submitted this year to NCA for one grant award.
The National Council on Alcoliolism was invited to observe the special
conference at the National Academy of Science at which two Nobel Prize
Winners and other distinguished scientists reviewed the basic research
position of NIAAA. At this time one of the reviewers stated that it
was a scandal, that of its budget NIAAA utilized only 8% for basic
research in comparison to budgets of other institutes utilizing up to
257o of their funds in this direction. This was particularly dramatic
in view of the many unanswered questions available for research answers
brought forth by other presentations at the conference.
Thus, we have great faith in the proposition that not only should basic
research continue in alcoholism, but that even in these times of compar-
ative financial need, these burning questions should have a solution
sought for them. This requires not only administrative dedication of
the institute, but congressional action to enlarge research budgets.
Other considerations are important in research on alcoholism. Many
ingenious methods have been used to provide research answers with
subhuman species in alcoholism. Mice, rats, goldfish, pigs, baboons
have all been utilized. However, there are times when such
species will not provide a satisfactory answer. Thus, while animal
research must continue, some human research will always remain
needed. In this area, the guarding of patients' rights under the
Helsinki Convention and the Nuremberg Laws must be preserved. The
209
Testimony of the National Council on Alcoholism to the President's Biomedical
Research Panel
National Council on Alcoholism urges 3 things in this regard:
1. That as far as possible local human rights
committees be utilized to grant authority and
monitor the activities in its own areas, as
(15)
proposed by Cowan. A balance must be struck
between protection of patients' rights and
an excessive burden of regulations, paperwork
and hazards for the experimenter.
2. That under the purview of human experimentation
come protocols including the provision of
alcohol to alcoholic patients as a treatment
modality - this would recognize NCA's Statement
(16)
on Abstinence as the Treatment for Alcoholism
which has also been accepted by the American
Medical Association Committee on Alcoholism of
its Council on Mental Health.
3. That adequate safeguards of confidentiality be
maintained as provided in new regulations
recently promulgated.
We would like to propose that biomedical research in alcoholism be
specifically designated so as to provide visibility to its funding. We
also submit for your consideration the request of one of our Board members
that a representative of the National Council on Alcoholism be chosen to
sit with your committee because of the wide variety of research interests
impinging on alcoholism.
210
The National Urban Coalition
1201 Connecticut Ave,, N.W. • Washington, D.C. 20036 • 202/293-7625
Written Statement to the President's Biomedical
Research Panel
by the
Health Task Force *
of the
National Urban Coalition
Richard G. Allen
Executive Vice President
Association of Western Hospitals
San Francisco, Calif.
Arthur H. Coleman, M.D.
Hunters Point-Bayview
Community Health Service
San Francisco, Calif.
Joseph Bernal
San Antonio, Tex.
Roberta Bessette
Supervisor, Combined Nursing
Service of Minneapolis
Pilot City Health Center
Minneapolis, Minn.
Lester Breslow, M.D.
Chairman, Department of
Preventive Medicine and Public
Health
Medical School, University of
California
Los Angeles, Calif.
Irene H. Butter, Ph.D.
Associate Professor
Bureau of Hospital Administration
School of Public Health, University
of Michigan
Ann Arbor, Mich.
Robert Campos
Research Associate, Addiction
Research Laboratory
Palo Alto, Calif.
James Chavez
Project Director
Servicios Utiles de Salud
Denver, Colo.
Howard Ennes
Vice President, Health Affairs
Equitable Life Assurance
Society of the U.S.
New York, N. Y.
Alfred Fisher
Executive Director
National Medical Association
Washington, D. C.
H. Jack Geiger , M.D.
Professor, Department of Community
Medicine
Health Sciences Center
State University of New York
at Stony Brook
Stony Brook, N. Y.
Feme M. Georges, M.D.
Former Center Director
Comprehensive Group Health
Services Center
Philadelphia, Pa.
Ernest Hardaway , II, D.D.S.
Office of Assistant Secretary
for Planning and Evaluation,
HEW
Rockville, Md .
Co-Chairpenons: Andrei
C/ia/rman; Walter N. Rothschild, |r. / President M Carl Holman
Heiskell, Vernon E, Jordan, Jr., James M. Roche, Sol M, Linowitz, Lucy Wilson Bens^
Secretary: Clifford L. Alexander, Jr. / Treasurer: Clcnn E Wallb
211
in, Joseph J. Bernal
John L. S. Holloman, Jr., M.D.
President, New York City Health
and Hospitals Corporation
New York, N.Y.
Arthur H. Hoyte, M.D.
Asst. Professor, Department of
Community Medicine and Inter-
. national Health, and
Director of the Office of Programs
for Student Development and
Community Affairs
Georgetown University Medical School
Washington, D.C.
Harry Huge
Arnold and Porter
Washington, D.C.
Stan Karson
Director, Clearinghouse on Corporate
Social Responsibility
Institute of Life Insurance
New York, N.Y.
Dr. Sanford Kravitz
Dean, School of Social Work
SUNY at Stony Brook
Stony Brook, N.Y.
Harry Lipscomb, M.D.
Bryan, Texas
Elaine Lowry
Baltimore, Md.
Barbara Mikulski
Councilwoman, Baltimore City
Council
Baltimore, Md.
C. Arden Miller, M.D.
Professor, Maternal and Child
Health
School of Public Health
University of North Carolina
Chapel Hill, N.C.
Warren Morse
Representative, Western Conference
of Teamsters
Burlingame, Calif.
Barbara Northrop
Forums Coordinator
National Health Council
New York, N.Y.
K. Patrick Okura
Institute of Mental Health
Rockville, Md.
George Pickett, M.D.
Director, Department of Public
Health and Welfare
San Mateo, Calif.
Miriam Viteritti
Herbert H. Lehman College
City University of New York
School of General Studies
Bronx, N.Y.
Lisbeth Bamberger Schorr
Washington, D.C.
George Silver, M.D.
Professor, School of Public Health
Yale University School of Medicine
New Haven, Conn.
Linda Z. Tarr-Whelan
Deputy Director of Program
Development
American Federation of State,
County and Municipal Employees
Washington, D.C.
Bonnie Towles
JRB, Inc.
McLean, Va .
Harvey Webb, Jr. D.D.S.
Director, Provident Comprehensive
Health Center
Baltimore, Md.
Dr. T. Franklin Williams
Medical Director
Monroe Community Hospital
Rochester, N.Y.
*Members of the Health Task Force of the National Urban Coalition
212
Testimony on behalf of the President's Biomedical Research Panel
by the Health Task Force of the National Urban Coalition presented
to the President's Biomedical Research Panel by Arthur H. Hoyte,
M.D. Dr. Hoyte is an Assistant Professor of Obstetrics-Gynecology
and Community Medicine at Georgetown University and will appear
in his capacity as a member of the National Urban Coalition's Task
Force .
The National Urban Coalition was established in 1967 as a national
non-profit organization. It is dedicated to the improvement of
the quality of life of the residents of urban communities. The
physical and mental health of these residents is, of course, one
of our major concerns. The organization views health, as defined
by the World Health Organization as "...a state of complete physical,
mental and social well-being and not merely the absence of disease
1
or infirmity. "
The Coalition welcomes the opportunity to testify at this hearing
on the topics that are to be emphasized. Alcoholism and drug
addiction have particular relevance to residents living in Urban
centers across the nation. They take a terrible toll in productive
lives, especially of young people, in our cities.
Although the National Urban Coalition has not been involved in
performing biomedical or behavioral research, the National Office,
and. at times "local" coalitions across the nation, have assisted
I
Clark, Duncan W. , MacMahon, Brian, Preventive Medicine .
Boston: Little., Brow.n 1960, p. 2.
213
universities, government agencies, independem: scientists etc.,
in obtaining data necessary to carry out studies related to al-
coholism, and drug addiction.
What type of research is being done to decrease population growth,
alcoholism and drug addiction in Urban Communities? Who is doing
it? How is it being done?
Concern as to what the answers to these three questions are explains
why the Health Task Force felt that it was imperative that a state-
ment be made to the Panel.
What is being done to decrease alcoholism and drug addiction in
urban areas?
It is our feeling that not enough research currently performed is
focused on prevention of these problems. Although the Coalition
supports continued molecular, biomedical and pharmacological
investigations focused on elucidating the basis of addiction,
especially narcotics and alcohol and favors support of similar types
of research in the area of population dynamics, it urges that the
Panel recommend greater financial support be earmarked for investi-
gating not only how the system, i.e. methods of allocating of
resources federal, state and local political decisions etc., con-
tribute to population, alcohol and drug problems; but what can be
done to lessen the evolution of problems in these areas. We are
requesting that there be a greater emphasis placed on applied
214
research focused on prevention and, if necessary, a reduction
in the support earmarked for studies focusing on the effects
of drug and alcohol abuse. Attention also should be paid to the
dissemination of results of studies to community groups and others
actually working with the problem.
Who is performing the research ?
At present it is estimated that colleges and universities per-
form about 61% of the nation's basic scientific work, while the
federal government and industry each perform about 16% and other
non-profit institutions 7%. We would be the first to acknowledge
that good research must be carried out by well-trained disciplined
scientists, and such individuals tend to be concentrated in
academic institutions. Unfortunately, the perspectives of a large
number of researchers concentrated at such institutions are too
often solidly cemented within the walls of academia.
The National Urban Coalition has no qualms about such experts
collecting data population dynamics, alcoholism and drug abuse
in urban communities, but has reservations about research designs
which impose upon the rights of those being studied; and tend to
be unresponsive to the fact that those being studied are human
beings who just happen to be subjects. In addition, the Coali-
tion has concerns as to how such data is interpreted and utilized.
^ The Chronicle of Higher Education, July 21, 1975 "Govern-
ment Plays Down News of Cutback in Research Aid"
215
once collected by the scientist or researcher who is "out of
touch" . All too often such data is interpreted and/or utilized
to blame the very people who are being victimized .
How is Research Being Done ?
At the present time there is too little coordination of the overall
research effort in the areas of population dynamics, alcoholism
and drug addiction. The lack of coordination within federal
agencies and between agencies results in the duplication of efforts ;
and increased costs. In addition, there is too little account-
ability placed on the researcher. In particular, too much re-
search for research sake is being performed. We recognize the
need to train researchers of tomorrow, but contend that this
must be done in a manner that makes them realize that they will
be held accountable by those who are supporting their training,
the taxpayer.
Of even greater concern to the National Urban Coalition is that
too much biomedical and behavioral research is undertaken without
any effort being made to obtain input from those most affected
by effects of overpopulation, alcoholism, and drug addition.
It is the contention of the National Urban Coalition that organiza-
tions such as itself should be encouraged to formally participate
in the designing of research projects, the collecting of data,
and the interpretation of the results. It can only do this by
216
either developing its own research capability or by federal
leverage (money) being utilized to encourage those within the
walls of academia to develop greater efforts to involve the
"community"
We suggest that greater emphasis and more funds be placed on
encouraging both greater dialogue and cooperation between the
scientist and the "community" as well as encouraging the develop-
ment of a "community" capability to perform at and critically
analyze research.
Finally, the Coalition contends, as we have indicated earlier,
that the results of such research are too narrowly disseminated.
All too often the "life" travel of the results of a given re-
search effort extends no farther than from a researcher ' s pen
to the bookshelves of a select few. The Panel should recommend
that greater efforts be made to disseminate relevant research
results and to educate a much broader base of the public on
how to better analyze and critically review the objectiv/es as
well as the results of biomedical and behavioral research.
In summary, the Health Task Force recommends the following:
1. Greater stress be placed on research focused on prevention
in the areas of population dynamics, drug abuse, and al-
coholism.
2. Greater accountability be placed on researchers in the
areas of population dynamics, drug abuse and alcoholism.
217
especially as related to responsiveness to "community" input
and "community" needs.
3. Discouragement of research in the areas of population dy-
namics, alcoholism and drug abuse that tend to "victimize
the victim" .
4. Discouragement of research that tends to disregard individual
rights and dignity, and the
5. Encouragement of the development of a greater capability
to perform, within community organizations, participate in,
and critically analyze research in population dynamics,
alcoholism and drug abuse being performed in urban settings.
Thank you for this opportunity to make this statement before your
panel.
**********
218
ALCOHOLISM: A COMMUNITY CONCERN
BY DR. HARVEY WEBB, JR., DIRECTOR, PROVIDENT HEALTH CENTER, BALTIMORE, MARYLAND
(MEMBER: NATIONAL URBAN COALITION TASK FORCE ON HEALTH)
INTRODUCTION
Mr. Chairman, members of the panel, I am Dr. Harvey Wehb, Jr.,
Director of Provident Health Center and Vice President of the national
DentaJ. Association. I am greatful for the opportunity to present to
you for consideration some deep concerns regarding a major problem
in our urban communities; alcoholism and abuse of alcohol., A few of
the major questions that must be addressed and for which complete
answers are not yet available are: VJhat is Alcoholism? V/hat is the
impact of alcohol on our society? V/hat are our approaches to
addressing the problem? V/hat problems do we encounter and what
resources are available and needed?
Before I attempt to present you with an overview of the problem
as seen from a community setting due recognition should be given the
foresight of the Congress of the United States in addressing alcoholism.
In 1970 public law 9I-616 changed the nature of our entire approach to
the disease of alcoholism. It officially declared that alcoholism was
a disease and shifted the emphasis from incarceration of persons consi-
dered moral deeenerates to an humane and empathic approach of seeking help
for sick members of our society. The legislation took the alcoholic out
of jail and put him under medical supervision. This transition has
not been smooth or easy because "as historical beings - the living links
between our civilization past and future - we are greatly influenced by
present and past attitudes" and practices in regard to alcohol, and we in
turn, affect the transmission of these and possibly new attitudes and
practices to the seemingly endless tomorrows of our civilization". In
addtion, "the transmission of attitudes and practices regarding alcohol
are of special concern because alcohol has been the most widely used
219
social beverage with drug properties in western civilization. It continues
to be so."
Brief History
The ingredients to make alcoholic beverages predate the Stone Age of
over 200 million years ago when water, plant sugar or starches and
yeast were present on earth. Early man was probably acquainted with
beer and wine. The early Moslem, Egyptian, Greeks and Romans used wine
in their feasts. The early Hindus made wine and Noah is stated to be
the first fanner to plant a vineyard and also the first to become
intoxicated. The Psalmist sang of its stimulating effects and its
progress follows the development of the western civilization. It has
been considered a devine spirit and Catholic and Prostestant churches
have condoned its 'use but not abuse. The first American Colonies knew
alcohol abuse and dunking and flogging were the Purtian punishment for
drunkenness on the Sabbath. By 1800 its economic value was known and
capitalized upon. An attempt by George Washington to put an excise tax
on the sale of whiskey caused a revolt and 13,000 state mailtiamen
were called out. Alcohol production was linked to the slave trade when
V/est Indies sugar crops were bought by New England merchants, converted
to rum and traded for slaves on the African coast.
Our nation has gone through temperance movements, prohibition to
isolated Alcohol Education. Today we face the same dilemma of who to
teach what about alcohol use and abuse and where the responsibility lies.
Therefore, Public Law 9I-616 has had a prophet impact on the health
professions and has forced us to reassess our societal obligations
and professional creeds. We thank the Congress for this new challenge.
220
To the Question of ^-Icoholisj
A patient being interviewed was asked what he knew about the abuse
of alcohol - He replied, "I know if you drink too cuch it will make you
drunk. Alcohol affects each person differently depending on a host of
physiological, psycological and physical factors. They include the
reason for drinking - the tolerence for alcohol and the general physical
and emotional state of the individual. Alcohol taken into the body is
mmediately absorbed through the tissue directly into the blood streara.
It appears to have an affinity for the brain and although its inital effects
may be stimulating, it is an anesthetic and a depressant.
Alcoholism is a disease affecting an estimated nine million persons.
There is no economic, social, race, sex or occupational group that
is inmune to alcoijiol. According to the American Medical Association's
Manual on Alcoholism "Alcoholism is an illness characterized by preoccu-
pation with alcohol and loss of control over its consumption such as to
lead usually to intoxification if drinking is begun; by chronicity; by
tendency toward relaose. It is typically associated with physical dis-
ability and impaired emotional, occupational, and/or social adjustments
as a direct consequence of persistent and excessive use. In short, alcoho-
lism is regarded as a type of drug dependence of pathological extent and
pattern, which ordinarily interferes seriously with. (a person's) total
health and his adaptation to this environment."
In human terms, what alcoholism means is a high incidence of broken families,
lost jobs, severe social maladjustment, long arrest records, lost work time,
economic privation, poor health and early death. Alcoholism is not seen by
any experts in the field as being nore prevalent in any one socio-economic
group than another. However, it might be claimed that as in all other in-
stances of health problems the poor suffer more when struck by alcoholism.
It is a serious contributing factor in many families' poverty and major
221
compounding factor in many other poverty families."
While there is not real agreeiient regarding the causes of alcoholisa,
there is a consensus among experts that it is an illness as distinct frora
moral weakness. As aji illness, it is seen as treatable. Its victiias are
not to be judged nor punished for being sick.
"The Federal Goverrjnent regards alcoholism as the third major illness
in this country (folloving nental illness and heart disease and ahead of
cancer) and the number one heal.th problem. H.E.V^ and the second report of
the National Comraission on Marijuana and Drug Abuse have indicated that
alcohol is the most abused drug in America. The .taerican Hospital Associ-
ation has stated that at least 30^ of all. medical-surgical patients are
hospitalized either directly or indirectly because of alcoholism. Most
of theses individuals are at one time or another involved in a drinking
episode which is mentally, spirtually and physically debilitating. They
are often rejected, alienated, and unemployable during this crisis period.
An unpublished study, (detailed data available from the Division of Alcoho-
lism Control), indicates that alcoholism cost over $U, 000, 000 at one
Baltimore City Hospital in a one-year period. Unfortimately in most cases,
only medical complications of alcoholism are treated; the chronic illness
itself is neglected. The alcoholic is released without having confronted
this major health problem and is caught up in a medical revolving door
which means repeated hospitalizations. For the homeless chronic alcoholic,
this has created special problems involving many life and death situations.
For many years the State Hospital's Alcoholic Rehabilitation Units have
attempted to provide, not only medical treatment for this population, but
also involvement in a total treatment program which will enable the alcoho-
lic to face his alcohol problem realistically and to begin a recovery
program."
222
The ' Imnact of -AJ-coholisa
Alcoholisa strikes all segizents of society, the unborn, the child, the
teenager and the adult. lio race, sex or ethinic origin is spared once alco-
hol abuse occurs.
A recent study of "Patterns of Malfon^ation in Offspring of Chroni
Alcoholic Mothers" - at the University of Vlashington described eight unrelated
children of three racial groups; all born to mothers who were chronic
alcoholics. The 'children has similar patterns of crainio-facial, limb and
cardio voscular defects associated with prenatal grow-th deficiency and post
natal development delay. All mothers drank excessively throughout preguacy.
'ivo mothers vera hospitalized with deleriun tremens (DT's). One child was
"born while the mother was in an alcoholic stupor. All of the children had
prenatal and postriatal growth deficiencies. Non of the children showed
catch-up growth during hospitcil admission for failure to thrive (for 6
children) and diiring foster care placement in three children.
The childrens hear! circumferences were below the 3rd percentile for
gestational age in T of the eight children. At age 1 year it had dropped
below the 3rd percentile for height age as well as for chronalogic aae in
five of six patients. In all cases the children's social and motor perfor-
mance were in accord with mental age than with chronologic age.
Fine motor coordination disfunction, weak grasp or poor eye hand
coordination was present in five or six patients tested. Most children
were delayed in gross motor performance. Five children were reported to
engage in some type of repetative self-stimulating behavior such as head
rolling, head banging or rocking.
One such severe case of "fetal alcohol syndorome" died at five days of
age with major heart defects, blood vessle abnormalities, extensive abnormal
brain cell formations and developments, and an incompletely developed brain.**
*Lancet 2-999 -1001 Ilovenber 3, 1973
**Ai-ch. Dis. Child li9:50-5'; Januai^y, 197lt
223
While living the child had severe respiratory problems, reduced eye growth
and clept palate.
Adolescent Drinking
Most states have laws limiting or preventing the purchase and con-
sumption of alcohol to persons under l8 or 21 years of age. Dr. Eosma Univ. of
^"■' > reported studies that show that by the time aldolescents have
reached the seventh grade most of them have tasted alcohol and that
71-92^ of our high school students had at least tasted. A study from
California showed that between 1970-1973 the percentage of high school
freshmen drinking once a week increased from 11 to 23/^ and the percentage
of senior girls drinking regularly increased from ll*j! to !)0a. Boys
seem to prefer drinking beer and whiskey away from hone in cars, alleys
and at uiichaparoned parties while girls tend to drink wine at home on
special occasions. "^^ reasons some teenagers drink are because "its the
thing to do", it will be fun", "getting high is something to talk about",
they feel "grown-up", "people will look down on them if they don't drink
and "their parents drink so why not"
For I96I-I97I the Federal Bureau of Investigation reports the number
of arrests of youth under I8 for drunkenness or for driving while
intoxicated had risen from 13,537 to 31,173-
These young people after five to 15 years of regular cr increased
drinking are our future alcoholics.
The Hard Facts
Data generated or compiled by the National Clearing House for Alcohol
Information reports the startling statistics of the effects of alcohol on
nearly 5/» of the American population. There are estimated to be more than
224
three million female and six million male alcoholics throughout our nation.
The American consumer spent in excess of twenty one million two hundred
eighty-eight thousand dollars annually on alcoholic products. The
results of consumption of these products are:
1. 16,000 illnesses in vhich the cause of death was indicated as
alcohol.
2. One half of the homicides and one third of all suicides were alcohol
related: ( 11,800 deaths.)
3. 28,000 or one half of all traffic accidents vere alcohol related.
k. 3^,800 or more than half non-highway accidental deaths were alcohol
related.
All together alcohol related problems cost the American economy
$25.37 billion dollars and 9-35 billion was due to loss of productivity.
Action in Progress
Since the problem of Alcoholism is multi-facilities the approaches
to re-education or cure of the disease requires a multi-pronged approach.
Over the last several years concentrated efforts to develop an
organized approach to the problem of alcoholism have been made by federal,
state and local agencies as well as industry and private groups and
individuals.
A degree of sophistication has emerged that indicates a basic
knowledge of the manifestation of the disease if not the true cause.
The problem has been attaclied', in the home with educational programs;
through the various communication media and on the job through manage-
ment and staff personnel committees who recognize the illness; in the
schools through educational programs for student understanding and
225
dialogue; in the churches through a more open acceptance of the disease as
a reality of life. Communities have established citizen inspired private
and public sponsored programs of prevention, hospitalization, Quartervay
houses. Halfway houses and rehabilitation programs', the Departments of
Safety and Traffic are using breath analysis, blood alcohol tests and
observing with close scrutiny of potential areas on or of abuse.
Voluntary agencies such as Alcoholism Council, Alcoholics Annoymous
and drug addiction associations and groups have also made significant
contributions toward resolution of the problem.
As a culmination of the major efforts expended during the last
several years the Accreditation Council for Psychiatric Facilities
has developed voluntary standards of performances for all alcoholism
programs with goals of quality care, efficient service and obtaining
quantifiable and comparable results.
These standards speak to the primacy of identification, evaluation
and- treatment . They require protection of human rights and dignity and
insist on the use of competent staff with non-discriminatory policies
regarding treatment and program participation.
Beyond the direct care aspects of treating alcoholism the standards
require the best use of collateral and complimentary com^munity resources.
As well ^ goal setting and measuring of quantitative and qualitative
goals are required as an integral part of written policies, procedures
and organizational plans to be evaluated on a regular basis.
Further, the organization of care and scope of service must include
well organized management, emergency care, inpatient care, intermediate
care, out-patient care, outreach, after care, or significantly relevant
combinations of services that would enhance patient improvement, recovery
or cure.
226
Problems of Support
The lavs shifted the responsibility for Alcoholism squarely on the
shoulders of the Health Professions and charged them very specifically
vith seeking out the roots of the problem and coming forth with a final
solution. Within the past four and a half years, since receiving that
mandate, we have made considerable progress. However, the scope of the
problem is massive. Previously, undeterminable needs, unavailable
knowledge and unforeseeable obstacles and concerns are now envisioned as
the foregoing statistics relate. I am certain that you will reflect
that some were anticipated prior to enactment of the legislation and
others will have far reaching implication upon pending health legislation
in other areas of poncern. In order that we take another major step to
resolve the pertinent causes of alcoholism, may I recommend:
1. Far more emphasis, resources, training and effort need to go
into preventive aspects of alcoholism without weakening the
existing programs or undermining current progress.
2. A more effective effort needs to be made to alleviate the
economic impact on the families of alcoholics and where the
poor are involved there should be more resources available
to rehabilitate, train in employable skills and motivate the
recovering alcoholic to see society in a more responsible
manner .
3. Inducement for the development of closer ties between industry,
small business , government and community at the neighborhood
level to insure a coordinated effort in the prevention, treat-
ment and rehabilitation and resocialization of alcoholics and
families of alcoholics.
h. The development of realistic resources through federal, state
and local, public, private and quasi public institutions and
individuals, adequate to meet the level of community need for
treatment of alcoholism.
5. The intensification of alcoholic treatment and rehabilitation
service within intermediate care and rehabiliation in acceptable
community based facilities where a comprehensive approach to
patient care can be provided.
227 , '
6. Enact g^ National Health Program that will lessen the
. categorial peacemeal approach to health care and proraote
an holistic continu um of preventive, diagnostic, thera-
peutic and rehabilitative service to the sick and
infirm without econoniic and social barriers.
7- Provide for adequate resources to insure long term
research on Biochemical, physiolog:ical, clinical, economic.
and sociological aspects of alcoholism.
We have received the charge, we have accepted the challenge. Now,
ve need adequate resources and support with which to proceed.
Thank you for the opportunity to present these views and concerns.
ATTACH-MENTS :
1. Lankford, L.L., Alcohol & History: Attitudes
2. Bosman W. , Alcoholism and Teenagers
3. Mandell, W. , Does the Type of Treatment Make A Difference?
228
Attach. 1
DIVISION OF ALCOKOLISH CONTROL
Departeent of I-!ental Hygiene
301 V/. Preston Street
Baltimorg, Maryland 21201
IN-SERVICE IPJ-IMDIG - AIJCOHOL A>.T) HISTORY: ATTIT?JDEo, PRACTICES ACT EDUCATION
Presented by:
Ludwig L. Lankford
Alcoholism Program Advisor
Department of Mental Hygiene
State Office Building
301 VI. Preston Street
Balti.Tiore, Maryland 21201
I. Introduction - It is not possible in 1'^ hours to cover all the available
information on alcohol, its uses, attitudes regarding it and alcohol education.
Even if it i;ere possible, it would probably not be the best way of training
people in alcohol education. Since we can't begin to cover all of the contentj
let us consider this concept:
A. As historical beings - the living link between our civilization
past and future -'we are greatly influenced by present and past attitudes and
practices in regard to alcohol, and we, in turn, affect the transmission of
these and possibly new attitudes and practices to the seemingly endless
tomorrows of our civilization.
B. The transmission of attitudes and practices regarding alcohol are
of special concern because alcohol has been the most widely used social beverage
with drug properties in our V/estern civilization. It continues to be so.
C. As a significant link we are continually affecting the attitudes
and practices v;e pass on to today's students and future generations.
D. VJe need to assume responsibility for the attitudes and practices
we transmit either overtly or covertly.
n. Early History of Beverage Alcohol
A, Alcoholic beverages caTie before civilization.
1. During the Pre-Stone Age - 200 million years ago - the materials
necessary fcr its production - water, plant sugars or starches and yoast - were
present on earth.
2. Old Stone Age Man was acquainted v;ith beer and vjine.
3. There is some reason to believe man learned to brew beer even
before he learned to bake bread,
h. A Mcsopot-omiaii cunoifona tablet of 3000 B.C. i-ecords a daily
wage paid to a IsborGr of "boer and bread for one day,"
229
IN-SIiR'/ ICE TPJ.IT^IX- - ALCGHCL ACT HISTORY: ATTI^JDHS, PR/.CTICES AlID rruCATIO?!
5. Cede of HajTCTirabi contained rec^lations about drinking and ths
dispo rzing of" ".ri. ns.
6. With ^^TDtians, Greeks and Kenans, wine was the usual beverage
of the feasts.
7. The "Rip-'^'eda", earliest literary vork of the Hindus refers to
"sura" a drink r.ade of grain and honey.
8. In the Eible, Noah is said to be the first farr.er to plant a
"Vineyard. He also nade vine and became intoxicaLed on it (Genesis 9:20).
(a) The Psalmist (Psalm 10a: l5) considered wine a gift from
God, vjhich may "cheer man's he?rt, makinc^ his face brighter than oil."
(b) Paul sugf^ested that Timothy take a little wine "for the
good of your dit^estion and for your irequant attacks of illness" (Timothy 5:23).
(c) Jesus' first miracle was the changing of water to wine
at Cana (John 2:1).
(d) Paul relegated drunkenness to the works of the "night"
(Gslatians ?:8). He nlaced it among the stumbling bloclrs of gluttony
(Romans lb: 20).
9. The opening of the Christian era and the fall of classical
civilization saw no decrease in the use of alcoholic beverages .
10. Scandinavians prepared and used great quantities of "nead", a
beverage made from fermented honey. Our word "honeymoon" comes from their
ancient custcr. of holdin," a 30 day feast in honor of a wedding at v/hich the
primary activity war drinking mead (honey-wine).
11. Throughout the Middle Ages the use of alcoholic beverages was
part of Western culture.
12. V/ine became an important corjnodity in the commerce of Europe.
(a) Geoffrey Chaucer, llith century English Poet, vias paid
by the king in barrels of wine for his service as court emissary.
(b) Tolls for the use of certain English roads were often
paid in beer.
13. The Arabian, Rha2es, is credited v;ith the discovery of
distillation in the Tenth Century. Since the spirit of the product comes off
in such 3 finely divided condition 3s to be invisible, it vjas called "Al-Kohl",
an Arabian v/ord meaning; "finely divided spirit." Tliis hr.s come to be our v/ord
"alcohol." The first distilled liquors were used as medicine. V.Tien they
became more plentiful and cheaper, they began to br. used widely as beverages.
111. First important restriction against the use of alcohol was
during the rise of Moharjrjedanism which created a "dry" area from the Adriatic
Sea around the I'-editerranean to the Straits of Gibraltar. There was no
formal prohibition .and liquor could be purchased.
230
IH-5ER7ICF. TRADJn:G - AirOHCL AND HISTORY: ATTITUDF3 , PRACTICES AMD EDUCATION
1$. After the Reformation, both the Catholic and Protestant Churches
condemned drunkenness, but not drin!:ing.
16. Even John Uesley, founder of Mathodisnj was not opposed to the
moderate use of brewed beverages, beer. ^
III. Alcoholic Beverag;es in Early 'America
A. The history of the use of alcoholic beverages in America begins
with the very first colonization of North America.
B. The Puritans in the Massachusetts Bay Colony did not prohibit
drinking, but punished severely, with dunking or flogging, citizens v;ho were
found to be intoxicated, especially on the Sabbath.
C. By 1800, alcoholic beverage had become a basic part of the
U.S. economy.
D. In 17?Ii an open revolt in Western Pennsylvania occurred when the
federal government atte.T^ited to put an excise tax on whiskey produced for
sale. President Washington felt compelled to call out 13,000 state militiamen,
E. Early U.S. alcohol production was linked to the slave trade.
1. Before the revolution. New England merchants bought sugar
from the French islands of the V/est Indies.
2. They converted the sugar into rum and traded it for slaves
on the African coast.
3. This ended when the British imposed the Sugar Act, forcing
colonial merchants to trade at less profit with the British V/est Indies'
sugar growers.
h. After the ^evolution, during Jefferson's administration,
fvirther importation of slaves was prohibited.
IV, The growth of the Temperance Movement
A. With, the acceptance of alcoholic beverages, especially distilled
spirits, as a household corTiodity and a part of the ecoromy came a {^rowing
suspension that alcohol, particularly rum and whiskey, was involved in some
social, health and moral problems in the U.S.
B. "Temperance" groups were formed to encourage people to be moderate
in their use of alcohol. The early proups were generally religiously affil-
iated and dedicated to the thesis that any abuse of the body was sinful. They
were for moderation, not total abstinence.
C. Farm groups, business groups, religious organizations, legislatures,
physicians and others focused on combatting alcohol related problems.
D. In 1865 the per capita consuir.ption of distilled beverages was
twice as high as it is today.
231
7N-SFP.VIGE TR^^.Tl.I^G - ATXOHOL AM) HTSTC-RY: AniTUDES, FR-ICTICCS Arm EDUCATION
E. Much of the drinking at that tii.ie was done at taverns and road
houses in all or predcninately male groups.
F. Between 1790 and I8h0 a variety of groups with differing approaches
tried to deal with alcohol problems with varying degrees of success.
V. The Classical Teripcrance Movement
A. By the l8L0's all conflict concerning approaches to alcohol
problems was almost entirely resolved in the philosophy that was to dominate
American society for the next 100 years, until 19hO.
B. No longer was there any question about the problematic substance.
All distilled spirits and brewed alcoholic beverages caused the problems.
C. No longer was there disagreement as to v;hat the ^ible had to say.
The new position was very clear - all biblical references to alcohol were
negative and hostile. Favorable references referred to unfermsnted grape juice,
D. In terms of tactics, voluntary decisions for abstinence and
abstinent models became secondary to indoctrination (education) and imposition
of punitive sanctions for not abstaining.
E. Legislative action against alcohol, followed by strong enforcement,
became equally as Irtportant as education.
F. In terms of education, legislative action to guarantee all-inclusive
activity of the preferred type was to became of primary importance.
G. f elden Bacon of Rutgers says "That it is difficult to adequately
communicate tl'.e enormous success of this venture." The classical temperance
movement influenced the feeling and thinking of the whole society about alcohol
and still does.
H. The V/omen's Christian Temperance Union, founded in l87h, was a
significant organization in this movement.
1. Had an abstinence pledge
2. V/anted total abstinence taught in physiology ' and hygiene
courses in schools.
3. Mary Hunt, first director of the Union's Department of
Scientific Temperance.
(a) Developed graded literature and library materials.
(b) Some schools accepted materials, others did not.
h. The Union pushed hard for the teaching of "Scientific
Temperance" in the schools. Vermont made it mandatory in 1882. Twenty years
later every state including D-C. had done so.
232
I N-SERVICE TRAKIt.'G - ADCOHOL ANTI HISTOP.Y: ATTITUDES, PR-J^CTICES AMD EDt'CATICJI
$. WCTU Educational Objectives -
(a) To reach all children.
(b) To teach demonstrated facts about the nature and effects
of alcohol and other narcotics.
(c) To give this instruction as part of hygiene.
6. VfCTO published "The School Physiological Journal" for lecturers
and teachers.
I. The Philosophy of the Classical Temperance Movement
1. The use of alcohol leads inevitably to individual and social
deterioration and disaster.
2. Alcohol is evil - spiritually sinful, physiologically poison,
and legally in terms of crime.
3. Conversely alcohol serves no useful purpose. At best it is
a second or third rate way of raising taxes.
h. If there is less alcohol there will be less use, so limit
distribution.
$. Every attack possible should be leveled against its distribution,
6. Finally, all drinking is the same, all drinkers the same and
they all are bad.
J. Three distinct pathways stemmed from the classical Temperance
Movement and its well articulated philosophy.
1. Of course, there v;ere the supporters of the movement. This
group was not exceedingly large.
2. The second group was the "wets", a defensive positive largely
consistinr of denials of the Movement's position and of a series of tactics to
block or weaken the Movement's program. This was hardly a pooitivn phi 1 osopl^or.
3. The third group had t-ho ]arg«bt number of people and probably
was enormous during the past hO years. This was the "Avoiders".
(a) Thousands of them voted against prohibition, but were not
for the "wet" position.
(b) Many voted against some or all parts of the availability
of alcohol, but they were not voting for the Movement.
U, still, there was only one philosophy - Classical Temperance
Movement.
233
TO-SERVICE TR-ainiNG - MJZIiOL AND HISTORY: ATTirJDES, PRA.CTICES AirP rpL'CATIGM
5. For one hundred years, until 19U0, this was a monalithic, r^ulti-
concerned and jealously protected position.
(a) The ilovement provided all the leaders, doctors, scientists,
information, and clergy.
(b) There was no corapetition, but opposition ("vreto") was
velcoined and encouraged.
VI. Prohibition and After
A. Under the leadership of I'lary H. Hunt and Frances L. V.'illard the
WCTU v;orked hard for legal prohibition and complete prohibition.
B. Between lS7h and 1919, thirty-three states adopted prohibition
of some kind. Sixty-ei;^ht percent of the U.S. population was affected, SS%
of U.S. Territory''.
C. On January l6, 1920, the l8th Anendr.ent to the Constitution va,5
declared law, and 177,000 saloons, l,2ii7 brev;eries and 507 distilleries in the
United States closed,
D. Prohibition lasted for 13 years (1920-1933) and its merits are
still bein^ argued today.
r. Organized opposition to the enforcement of the l8th Amendment began
even before the law becarra operative. The Association Against the Prohibition
Amendment was established in April 1919. Its announced purposes were to prevent
the country from goinp, dry under wartime prohibition on July 1, 1919, and to
prevent the l8th Amendment from bficoming operative on January l6, 1920. At
first, its mc;nbers came chiefly from the brewins: industry.
F. The Volstead Act, provided the machinery for administering and
enforcing the Amendment, contained more than sixty provisions including the
prohibiting of the manufacturing and distribution of both brewed and distilled
spirits containing 1/2 of one percent (or more) of alcohol. Purchasing illegal
beverages was not forbidden.
1. Some of the weaknesses in the Volstead Act included:
(a) Enforcement was placed in the Treasviry DepAi-tiihaiif. x-tit-.ho-r
than the Justice Department.
(b) It permitted the production of alcohol for scientific,
industrial, medicinal and sacranenta] purposes, neceGsit-ating a co;nplicated
license and permit system incapc.ble of adequate su^rvision.
(c) At no time was there adequate personnel for enforcement.
(d) The enforcement personnel did not become Civil Service
until 1927.
(e) Lack of local support for prohibition often made arrest
and conviction of liquor smu^^lers and bootleggers difficult.
23h
IN-SERVICE TRAi;!r?..»3 - ALCOHOL A?n3 HISTORY: ATHTUDrS, PRACTICI:S AKD EDUCATIOM
G. Maryland was the only stata in the Union not to pass a state law
sindlar to the Volstead Act, enabling local authorities to arrest and prosecute
Illegal nanuTacturing and distribution. Only federal agonts made arrests for
violations in Maryland.
H. The high point of sentiment for repeal developed during 1931 and
was reflected in the attitude of the two major parties in preparation of
platforms adopted at the 1932 national conventions.
1. Nine days after his inauguration President Roosevelt called on
Congress to modify the Volstead Act so as to legalize beverages containing not
more than 3.2 per cent alcohol by weight.
I. The repeal of Prohibition has been variously credited to:
1, The weaknesses of the Volstead Act and related enforcement
problems .
2. Popular opposition to what some people thought was the
Establishment (V^hite, Anglo-Saxon Protestants) forcing their morality on
the nation.
J. The i^epeal of the l8th Amendment v/as accomplished by the adoption
of tha 21st Amendment in 1933. Kach state set up controls for liquor. Sane
decided to use local option elections to decide the wet-dry issue.
K. Governments at both state and federal level have passed laws
concerning drunk drivinr; and the sale of alcohol to minors.
VII. Alcohol Education
A. About 1893 a professional group called the Committee of Fifty to
Investigate the Liquor Traffic (not associated with Temperance groups) began
functioning. In 1905 its reports stated:
1, "Scientific temperance" instruction in public schools is
unscientific and undesirable.
B. Education responded to the Classical Temperance Movement by
isolatinfT alcohol education. This is still true today.
1, Other responses' vera wayu of avoiding the vet/drycoatrcrrgTsy ,
but the message is still clear "Don't Drink".
ia) Schools have o'ther bigger problems.
(b) Schools are asked to teach special subjects by every known
pressure group.
(c) There is question about teaching morality in the schools,
(d) Isn't alcohol a family - church - community problem.
235
IN-SERVICE TRAINING - klCOHOL ANT) HISTORY: ATTITUDES, FRjaCTICES AND EDUCATTCN
(e) Slick, well organized riaterials, lectures, discussion
groups, films, exprrir.ent, all focusin<^ on metabolis:Ti, physiology, bi-
ochemistry or biology.
(f) Students learn the state laws.
(r;) Alcoholism education.
(h) Alcohol, tobacco and drag education.
C. Heed to integrate alcohol education, focus on the decision making
process (Maryland State Board of Education Conceptual Approach).
Sources - Notes on Alcohol Education for Teachers , Chapter I, Bulletin 371,
Department of t^ducation and Department of Public Health Alcoholism
Program, Lansing, i'^ichigan, January, 196? .
Alcohol Education - Conference. Proceedings , Education on Alcohol: A
Background S-catement by Selden U. Bacon, Ph.D., U.S. Department of
Health, Education, and V/elfare, March I966.
Alcohol Education for Classroom and Comjr.unity - A Source Book for
Educators , page 51-53, McGraw-Hill Book Company, 19'iU.
Drinking and Intoxication - page 368-382, Journal of Studies on
Alcohol, Incorporated, New Haven, Connecticut, 1959.
LLL/jp
2/19/70
236
Alcoholism Section
From the Subcommittoo on Alcoholism ol the Medical and
Chirurgical Faculty of the State of Maryland
Alcoholism and Teenagers
WILLEM G.A. BOSMA, MD
Director, Division of
Alcoholism and Drug Abuse
Psychiatric Institute
University of Maryland Hospital
721 W. Redwood St.,
Baltimore, MD 21201.
Seyid reprint and information requests to Dr. Bosma.
The following paper was delivered as the Keynote
Address of the recent Annual Conference of the Na-
tional Council on Alcoholism at Denver.
Introduction
During the last decade, a great deal of publicity has
been given to alcohol. The press, television and radio
are daily confronting us with facts about drinking,
alcoholism ai)d the prevention of alcoholism. Care is
taken to distinguish between the social drinker and the
pathological drinker, the alcoholic and signs of alco-
holic behavior are enumerated. Only one area has
been neglected in this barrage of information; namely,
the area of adolescent drinking. Adolescent drinking
remains shrouded in all the mystery and misconcep-
tions formerly surrounding the alcoholic.
Teenagers wlm chink arc innnediately suspect.
Popular opinion ronchides that their drinking in-
evitably results in promiscuous or destruclive behavior.
They pretcr "hard" liquor to beer ami mostly take
their drinking outside the home, "on the sly," so to
speak. Newspapers never fail to magnify stories about
allegedly drunk teenage diivcrs, leading to the conclu-
sion that teenagers under the inlluencc of alcohol
cause more accidents tlian aduhs. .Similar stories about
adults rarely, if ever, apjK'ar in tliese same newspapers.
Furthermore, an increase ol talal accidents among
teenage driver-, is predicted when the legal chinking
age is lowered to 18, as it already lias been in a number
of states.
None ol the above premises is true upon closer ob-
ser\'ation. Tliey are the result of tlic emotional adult
attitude towards adolescents in general, but pai-
ticularly toward adolescent drinking.
The excesses of a small minority mistakenly become
the norm for all adolescents.
That is not to say that adolescent drinking should
not be an area of concern. After all, tiie adcjlescents
of today are the adidts and the alcoholics of tomorrow.
Alcoholism remains one of the major diseases in this
country. One certain way to reduce the number of
alcoholics is to prevent toclay's teenager Irom becoming
tomorrow's alcoholic.
This paper, then, will seek to deal with four areas:
1. The drinking habits of adolescents.
2. The adolescents who are or may become prob-
lem drinkers.
3. The effect of parental alcoholism on childrca
and teenagers.
4. Some suggestions as to what can be done.
Facts About Adolescent Drinking
Most states restrict the purchase and consumpti. n
of alcohol to people over 18 or 21 years of age. T; .;
legal restriction does not prevent so-called "under-a<: "
drinking, however. By the time they reach 7th grat ,
most adolescents have "tasted" a little alcohol. T s
number increases with age.
In high school, from 71-92% of the students h- z
at least a "taste."i This is not surprising, since d '-
dren grow up in an environment in which alcohoi •$
an important facet. At age six, about 40% were able to
recognize the smell, and at age 10, this had risen Lo
60%, according to one study. This study further dis-
covered that as early as age six, only one in seven
children failed to interpret the behavior of a drunk
reeling in a street as being the outcome of drinking.2
An adolescent, then, does not take a drink, in a
vacuum, so to speak. He has long been acquainted
with alcohol and is aware of the manifestations of
drunken behavior. Apart from an initial tasting ex-
perience, however, most adolescents claim to be non-
drinkers. Of those who admit to drinking, most drink
infrecpicntly and in moderation. A study of the 1960s
indicates that about 10% drink regularly, meaning
once a week.'
A later studv in California shows that between 1970
and 197.'1 the [x^icentage of high sih(H)l freshmen
drinking once a week increased from 11% to 2''l%.
The percentage of senior girls chinking regularly in-
creased from 11% to '1.1% and senior boys from 27%
to 40%.^
This woidd seem to be an alarming increase in
ndolescent drinking over a short [Kjriod of time, but
it does not cl.iim to predict nmch alwut heavy drink-
ing among these .iclolesreiiis. Adolescents may simply
feel IrccT nouaclays to tell the liiilh al)<)tit tlicir chink-
ing habits.
Boys and girls differ in drinking preferences. Boys
lend to chink beer and whiskey. Tliey drink away from
home, in cars, alleys and at unch,q)eronecl parties.
Girls piefer drinking wine at home inider parental
siqjcivision on s|>ecial occasions, such as parties or
birthdays.
.Most adolescents feel that their parents disapprove
of their drinking, except for the occasional "tasting."
A lew adolescents admit to having been drunk,
although this getting drinik is in no way comparnble
to an adult's being drunk. The adolescent after over-
indulging usually quickly becomes physically ill.
Why Does an Adolescent Drink?
The teenagers of my acquaintance gave a variety
of answers lor their drinking or not drinking.
62 MD Stale Med, J. Ju
237
" let'iiagers drink bccnu.se it is thing to ilo."
"If yoii drink, well, you want to make a good im-
pression on him. At that time, it seems the thing to
say, so )ou say yes."
"Teenagers diirik hciause ihcy have some jjrccon-
ceived idea that it will he lim. "
"Getting 'high' is something to talk alM)iit later.
When yon're with a gronp and eNeiyone is blagging
about having been to drinking parlies, von feel \()U
need to have had some sm.ishing diinking experience."
"My parents drink, so uhy shonldn't Ir"
"Because it is liin to fani.isi/e."
"When \on drink, \on leel grown up."
"If \(>n'ie with .1 group and lhe\ loiik ihtwu on
drinking, 5011 ilon'l drink. "
One olher reason teenagcis i.ike iheii (nst drink is
not mentioned above; plain old (iniositv ,is to the
actual eflccts of ahohol tauses ni.inv ,1 leciiagei (o lake
his first drink. A icason adoksienis (oniinue to drink
is that it is a widespie.id soiial ( ustom in this (onn
try;" ("It is the thing to do") . R.illier than ils being
a rebellion against p.irenlal authoiit\, ,is it is often
considered, it is an attempt to join in an .idnlt social
custom.
Many adolescents feel th.it drinking gives tbein ;in
added dimension of maturity. I bev .ne indnlging in
"forbidden fruit" and ])artaking of th.e adult world.
There is a scene in the recent film, .liiicricnu CtaljtHi,
where the pseudosophisticated girl eggs on the under-
age boy to buy some of the "hard stuff." Drinking
seems to be her way of proving she is older and more
mature than she actually is. Drinking is also reg.irdcd
here as the way to have fun.
The early adolescent seems to be little-inlluenced by
social or peer group pressure; an adolescent is not re-
quired to drink even if his peer group does. Frecpient-
ly, among adults, the nondrinker at a social gathering
is scorned or ridiculed. Not so among early adolescents.
Not only are they not rccjuired to drink, but the non-
drinker is more highly regarded than the drinker, even
by those who drink themselves. Drinking or not drink-
ing does not seem to effect popularity, membership in
social clubs or the social standing of these teenagers.
"Doing one's own thing" is a legitimate reflection of
early adolescent attitudes.
•
As the adolescent reaches his upper teens, however,
peer group pressure seems to play an increasingly-large
role in his decision as to whether to drink.'' These
"eenagers no longer drink predominantly at home
under the watchful pareirtal eye, but rather among
themselves. To experiment with alcohol is a teenage
norm, and to deviate from this norm has its penalties
rmong teenagers as among adults. Again, "It is the
-hing to do."
There is no complete answer as to why a teenager
drinks. What is clear, however, is that attitudes of
idolescents toward drinking most clearly reflect those
of their parents. No other single factor— race, religion
or peer group behavior— is as important as the drinking
pattern of the p;iients in the adolescent's decision to
drink, not to drink, or to overindulge. Our own at-
titudes— straiglit-forward, ambivalent or pathological-
are certain to be rellected in our children.'^
.\ study in GliLsgow encompassing adolescents who
.ibstain, drink lightly, moderately and heavily made
some interesting lindings as to how teenagers regard
their own drinking. They felt that alcohol confers
n|>c)ii iheni certain ciualities, such as toughness, ma-
turity, soci.ibility and attractiveness to the opposite
sex. '] he noiuhinker is seen as weak and unsociable
Interestingly cnougli, bv all the groups above, the
heaw drinker is also \iewecl as unattractive, unsociable,
lough ,ind ichellious.*'
ihese lindings sliould leassnie mosi of us as to the
drinking habits of the v.ist majority of adolescents.
I'hey aie not the rowch drunken bunch we are led to
believe despite the lact that most ;idolesceuts do drink
.iiiil leel (C)iiipelled to do so by peer ])icssnre.
A minoiity of adolescents, howcxer, do drink too
iiiiiih 01 (liiiik in such a way that the likelihood of
ilieir h.ivnig lutnie probleins with .ikoliol is increased.
Ihese .ulolescculs h:i\c a clilleient p.iucrn or reason
for drinking. rhe\ will bi some ol the alcoholics of
tomorrcnv.
Ironicilly. iIksc adolescents generally start to drink
later than their niodeiaie drinking fellows. This in-
dicates that lliev prob.ibly learned to use alcohol them-
selves, wilhout the guiding influence of a parent.'
The reason gi\eu by some that they drink is be-
cause "It is Inn to fantasi/e," and indicates that alcohol
is used as a drug enabling them to daydream in a
pleasant way. These adolescents indicate a need for the
mind-altering qualities of alcohol, a need to relax in
order to indulge in a given activity.
.\ young man who has to liave a beer before he can
take part in a party is using alcohol strictly for its
elfects. The one who insists on drag-racing after drink-
ing, the girl who uses alcohol as an excuse to be
promiscuous, the boy who uses alcohol to express ag-
gressive and destructive behavior, these are the ones
we should be aware of and help. They have deep-
seated, underlying pathology. Alcohol either helps
them to feel "normal" and "up to par" with their
peers, or alcohol is used as a vehicle to express their
frequently destructive pathology or social ineptitude.
•
In a survey in Nassau County, New 'York, it was
found that 2% of the students drank about one-quarter
of all the alcoholic beverages consumed in a group
of 1,000 high school studeirts.i" Most of them were
"high" at least once a week. Of this group, 14 were boys
and five were girls.
These heavy-drinking teenagers had a very similar
attitude towards alcohol. They used alcohol specifically
for its effects. They drank to get drunk or at least to
feel more comfortable in difficult ci: cumstances like
parties where they would have to approach and ask
girls to dance. They had occasionally been in trouble
due to their drinking: picked up by the police for
1975 MD State Med. J. 63
238
"drunken driving," "possession of alcoliol" and "ag-
gressive and destructive behavior. "
One 17-year-old, white middle-class, high school
junior was drunk nearly every weekend. He had to
have a couple of beers before he could comfortably go
to a party. He wanted to have a girlfriend but was very
shy, and could only talk with girls after he had been
drinking. He was referred to a psychiatrist by the local
judge after being picked up three times by the state
police for suspicion of drunken driving and possession
of alcohol.
Another boy was referred by the school authorities
after many instances of aggressive behavior in school
functions, parties and football games. On all (Kcasions
he -had been drinking heavily.
Both boys contended that their parents did not
agree with their drinking and did not actually know
how much they drank. On the other hand, one father
was an alcoholic while the other drank heavily.
These boys cannot be characterized as alcoholics.
Strictly speaking, to become an alcoholic takes from
five to 15 years of heavy drinking. They are examples
of adolescent drinking, that will doubtless develop into
problem drinking. They have imdcrlying psychologital
disorders and need counseling and perhaps |)sy(hialri(
help. To recrtgnize and treat these generally hea\y
drinkers is the challenge of today, in order to pie\ciu
their becoming tomorrow's problem drinkers.
Drugs and Alcohol
Lately, people have Iwen spccul.iluig tlial adolesccnls
have been turning away Irom drugs to .lUoliol. Ii
might better be said that adolesicius ue\ei slopped
drinking. Their use ol aUobol ^^■as o\eishatl(>\\c(l i)\
our concern with the so-ialleii "diug luliure." I Ik-
youth drug culture is still with us, cncii ihougli iiiiiioii
wide, the use of drugs seems Ui li:i\e peaked aboul
1970. The youth ol today seem lo be more knowledge-
able about drug use, .nul as .1 icsuli. iIrtc is ii ss duig
abuse in terms of deaths Iroiii (>\eidosis .md so on. Ilie
]>ublicity given the drug lulluie li.is abalc<l .is ,1 rcsull.
.Since the evils ol drug .iluisc Ikim been so \i\idh
des(ribed by the nu'dia, inau\ .1 unsgiiuled p.iu jU has
inged liis childreji lo diiuk i.ilhir than partake in llic
"drug cidtine." "II he uouUI oulv drink. I)i inking
never harmed mv." sa\s this p.uiiii. ()\ei looked is ilir
danger ol alcohol abuse, uliidi is e\('iv hit ,is iusiilioiis
as drug addi< tiou.
In tlie last analysis, the use ol aholml .imong
adolescents il(jes seem to have iudeascd iji leceiu m.us.
not only because tliere is a letum lioui drugs to aliobol
l)ut also in ab.solute leruis: .iclolesceuts aie diinknig
more as the previouslv-inenlioned San \l.ileo siud\
indicates.
Further examples; lu a reierit joundup ol nniuK
college sttidents at a .\ew |erse) lesoit, oiih a li.indful
of the more than 1(10 arrests weic on m,i]i{M,iu.i
charges. The rest weie lor diuukenncss. lioni I'.Hil
to 1971, the Federal Uure.ui ol linestig.nion lepoi is
the number ol arrests ol \oiingsirrs iiiulei IK jni
drunkenness 01 I'oi ihi\ing wliile iino\ii .lU-d had liscn
from i;i,537 to 31,173, well over twice as many."
Alcoholics Anonymous has been reporting an in-
creased number of younger people among its members.
One reason for this is that alcoholism is no longer
considered the forbidden, shameful disease it once was,
and people are less reluctant to label themselves.
Another reason is that there is now a tendency tu
mix drugs and alcohol. This mixture hastens the dis
ease process of alcoholism. Physically, drugs and al
cohol have a potentiating effect and cause more dam
age more quickly in combination. Psychological de
terioration is also faster in the individual when drugs
and alcohol are used together.
Drinking, Driving and Sex
Theie are iew woi rics that parents have that are si
real but also so inevitable as the worries at the timi
the adolescent is legally allowed to drive. Indeed, Vi
vear-olds have more accidents and are more severely in-
jured through automobile accidents than any other age
groiij). The idea that the adolescent would then also
mix alcohol with driving "is for most parents unbear-
able, since many recent studies indicate that alcohol
use or abuse by drivers is closely-related to the chance
ol .utidents and is a factor in a high percentage of the
lat.dities on the highways.
Further iiuestigation, however, shows that the ])eople
iu\i>l\ed in these accidents with high blood-alcohol
le\els, a)e nearly all adults. Very few investigations
have been done into adolescents' driving under the
inliuciue ol alcoliol. Those that have been done, how-
ever, indie .ue ili.u lew teenagers drink and drive.
A stiiilv done in (>r,ind Rapids, Michigan in I9(il
slio\ved lb. 11 HI du\ iug accidents ol leenageis, none of
llie leen.igeis li.icl a blood-alcohol le\el that would in-
die .uc iin|)aiied clriMiig al)ilil\ ihiough high ingestion
ol .diohol I-
riie New |eise\ |>oli(e slopped :!()() cars with teenage
drivers (oniiug lioui .\ew ^'ovk vvheie- the leg.il drink-
ing age IS le)\\ei. '_' I \eisiis IH.i' .\ol one driver was
louuel lei be chiving iiuelei the inlliience of aUeihol.
\ii ineicMscel numliei e)l l.ilal automobile accidents
is |iicelie led ulieu ilie legal chinking age is reduced tei
IK. 1 lie liisui.ince Insiilule lor Highway Safety de-
bunks ill. 11 idea: "The l.iw change allected the peicep-
lieiii and 01 ic'poiliug ol alee>he)l involveiiient by the
police iiieiie til, 111 il allected the lalal clash rale.""
\\ here-. IS piexiously cliive'is IH-'JO, not of legal drinking
.igc. ,iie given ilie benelil of the doubt by a |>oliceman,
"iieii Venning 10 spoil the veiling person's record,"
lluv vvemlel lie eli.uged ,is all adult when the leg.il
eliinkiug ,ige beciuie- IK, I lieie uatiuallv leillenvs .in iii-
eie.ise 111 llic' luuiibc'i iil "chiviug tiiieUi llie inlluencc
eil aleohol' charges.
Ill Mieliig.in, Ihe luunber of 1 Hlei-L'l)-\ear-old dlivcis
vvliei vveie lepoitccl lei liavc' been chinking when they
vveie iuveilvc'd in l.ilal ei.islus. increased by I'il'^'J, in
1(17.'! ovei 1971. \el. lliev weie .iitu.ill) involved in
'-'9',, Icwei lal.il Hashes th.in lieloU' il was legal lei
eliiiik ai IK, .\ closer an.ilvsis ol oilier stalistics Ire-
i|uciill\ ie|iorled tei ee)iileiiiii the preiiidices abeiul
64 MD Stale Meed, J. June 1975
239
jdolcMCiu ciriiiking and driving k\\{ liirlhcr (oiiljini
that the situation docs not adnallv (hangc nnuli when
the legal drinking age is lowered.'^'
Our adolescents seem more aware ol the danger ol
niiNing alcohol with gasoline than we give them credit
for.
•
A small groii]) ol yonng drivers <.uise concern, how-
ever. Ihcse are the drivers who drink and at the same
time are Idled with hostility and a sense of alienation.
The einotional fa< tors of hostility present in a \onng
driver, as shown bv fist lights and arguments with older
people and alienation from school shown hy lower
grades, less studying and <|uiiling sdiool— coupled with
heavy drinking— caused a great numher of aiuoniohile
crashes and violations, according to an .\nierican in-
vestigating team reporting recentiv to the First Interna-
tional Conference on Driver Hehavior in Zurich '"
.■\Icohol in the hands of this unstahle adolescent is
a factor in a great many traffic accidents. A sinall pei
centage of adolescent drivers are indeed unstahle. but
they become the norm in the public eve.
.Another area of concern and confusion is alcohol
and sex. .Alcohol in our society has the reputation of
lessening inhibitions, but .ictually works as a depres-
sant, c]iiite the contrary eflect of an aphrodisiac. This
alcoholic "folk tale," however, is surelv not lost on oui
children and must have an influence on them.
The problem is that there seems to be no data on
this subject. The cited studies do not inchule this area.
Among the adolescents in my practice, sexual inter-
course was not directly caused by the use of alcohol.
In many cases, alcohol might have been used to over-
come anxieties and inhibitions. That is, the adolescent
drank because he had sexual probleins. In cases where
sex and alcohol were mixed, the decision to have inter-
course was made before the drinking began.
One 16-year-old girl, who was on the verge of losing
her boyfriend and also was sexually curious, made the
decision to have sexual intercourse. An elaborate ar-
rangement was set up. When she and her boyfriend
were together, they clrank to overcome anxieties, in-
hibitions, and guilt feelings. The relationship deterio-
rated very rapidly thereafter.
It seems reasonable to conclude that as among
■dults, alcohol is used by adolescents who are insecure
ir inadequate in the sexual area. The vast majority of
eenagers, however, woidd not be found to mix alcohol
ind sex as they have been found to mix alcohol and
Iriving.
Parental Alcoholism and the Adolescent
An area that has been totally overlooked until very
ecently is the influence of parental alcoholism in the
levelopment and stability of the children.
In recent studies, a direct correlation between paren-
tal alcoholism and childhood and adolescent disturb-
ances and maladjustments was uncovered." Of course,
many further investigations have to be done to see
whether the underlying problems of the parents caused
them to drink alcoholicly or the alcoholism per se, as
the reason. However, one indication that the alcohol-
ism was the ui.mm culprit was that the children ex-
posed to the more severe alcoholism of the parents
(the yoiuiger ones in the family) were more impaired
than the others.
In our inner-city pediatric clinic (children ages
2-IH) . we foinid that over 50% of the youngsters re-
ferred because of behavior disorders had an alcoholic
parent. .\ similar peicentage {K%) was found in a
suburban conununity mental health center. Of 200
adolcsceiUs re lerred because of "drug problems," 67%
had an alcoholic patent.
Of I2H male .idolesceuls on probation after court
consiclion, KL' had at Ic.ist one alcoholic parent. A sur-
vev ol successful adolescent suicides showed 2/3 of the
.ulolcscenis to have an alcoholic parent. In our adoles-
ceiu suicide clinic, we Heated 12 attem|)ts in adoles-
ccnis ranging Irom 12 to 17 years old. All these yoimg-
sieis had m.ulc- au attempt and one had succeeded at
ihe sec oud alleuipt.'"
Ol these 12. six bad an alcoholic parent, while
(i\e had ,i p.ueul with (|Meslic)uable alcoholism. Only
one voungsici had p.ucuts that clearly were not al-
coholic.
The clulchen of alcoholics aie the |)rincipals in a
hidden li.igedv. ThcN lend to lie totally ignored by
the piolessionals tre.iliug the alcoholic parents. And
ut. rescue h iiidicatcs that the alcoholic's children, the
most plastic and inipiessionable members of the family,
are most subject lo Ihe destructive influences of an
alcoholic p.iient.
•
The alcohcjlic in his luicomfortable and guilt-ridden
anesthesi/ed stale is luiable to establish a loving and
meaningful relationship with his child. The alcoholic
sees the world through a fog that is impenetrable to
the emotions of the [leople surroiuiding him or trying
to reach out to him. He isolates himself and this makes
it impossible for him to reach out or relate to others,
even his children. He is self-centered and preoccupied
with himself.
The children cannot turn for attention and love to
the spouse, either, since the other parent is often too
overcome with anger and frustration to be of any com-
fort. This parent most often has her own share of
inner-conflicts. Her inability to recognize the superficial
relationship with her spouse, her neurotic compulsion
to take care of or "mother" the alcoholic, leaves little
time for the child.
More often than not, she is even unable to provide
the child with a caring atmosphere, since it is no acci-
dent that she has picked an alcoholic spouse, (If it is
the mother who is the alcoholic, the situation is even
more desperate. Children, especially young children,
are more dependent on their mother, Obviously, alco-
holic mothers cannot care for either their children's
physical or emotional needs.)
The alcoholic's children react to this situation with
intense feelings of distrust, rejection, worthlessness and
repressed rage; then, the inconsistent, erratic be-
havior of the alcoholic and his spouse make the child
feel insecure. Thus, home life does not provide the
1975 MD State Med. J. 65
240
usual sense of security a haven from the frustration of
the outside world. In fact, the child is in constant fear
of physical violence, due to the aggressive behavior
of the alcoholic. He is also a witness to the constant
violence between his parents and fears the threats of
parental separation he so often hears.
This separation may occur from time to time, which
increases the child's apprehension and insecurity. "Who
will be there when 1 get home from school? How will
they react when 1 am there?" The situation at home is
further aggravated because the child emulates the par-
ent in taking out his pent-up frustrations violently on
his siblings.
It is obviously difficult for a child to identify in a
positive way with an alcoholic parent. Consciously, the
child rejects the ugly behavior he sees, but luiconscious-
ly he adopts the behavioral pattern of the imperfect
parent. This creates a confusion in the child's behavior
because of the conflict between his conscious view and
the imconscious image which ha^ Ijeen imprinted.
The confusion is manifest in the child's behavior in
schcxjl and other areas of socialization. School mental
health workers frequently find a startling correlation
between a child's adjustment problems and his parent's
alcoholic behavior. The alcoholic's child is unable to
concentrate in school due to his anxieties about his
home life. He'ljrings many of his aggressions to school
with him and is likely to antagonize his teachers and
classmates by his antisocial behavior.
The isolated behavior of the alcoholic sets a pattern
for the child. The dulled state of the alcoholic, his
erratic, violent behavior isolates him from society anti
his family— he is unable to relate to oi c\cn ii)lcralc
other jieople: rathei, he is lost in his own peisoual
world.
The child's j)attern of isolation is leinlorced by his
shame at his parent's home lielunior. Obviouslv, the
child does not want t)utsiders to know about his home
situation. He presents a false hoiit lo his peers hiii^;
or fantasizing about his paunts. This pre\enls his
fonning close friendships. Simc such Ineiulships .ne .1
necessary youthful e\perieri(e, the (hiki li.is .ilieady
set a i)atterM ol lile that c;in le.iil 10 .lUnhol. ihug
abuse or other mal.nljusluients.
A recent study indicate<l that male adoksceiu chil-
dren of alcoholics were asscrti\e, rtlKllious and ii\crl\
hostile with an overemphasis on mast iiliuil^ '■' I'lu
adolescent girls on the other hand, tended to be sell
defeating, vulnerable, pessimistic, uithdiauii and llu<-
tuating in their moods-'" In shoii, these (hildieu ha\c
behavior problems.
Although these cliildren are obvioush disturbed
throughout their de\elopmeiU, they are most symp
tomatic in early and l.ite adolescence. TJiex do not do
well in school since they hnd it hard to conceiurate.
They complain life is not fiui. 1 hey are often forced
to take over the ilemaiuliug role of the parent— cook
the meals, clean the house, |)ut younger children lo
bed— since a parent is often either missing or emo-
tionally and physically incapacitated.
School is no better. Whenever the diild is out ol the
home, he is constantly anxious about how things will
be when he returns. He cannot rely on the parents at
home and he isolates himself at school because he is
ashamed to tell anyone about his anxieties. He fears
a humiliating pity from those who might find him out.
Except for the concern of an occasional individual,
doctor, teacher or minister who looks below the surface
behavior, this child can expect little attention or com-
fort from society.
If the alcoholic parent stops drinking, the situation
does not seem to improve much. Short-term sobriety
generally makes matters worse. The disillusionment of
the child when the parent resumes drinking is shatter-
ing. All the hopes and dreams of having a so-called
"normal" parent are once again crushed.
If the alcoholic stays sober, a normal family life does
not automatically follow. The individual is often too
preoccupied with his recovery to even think about re-
establishing a relationship with his wife and children.
The strained feeling between the spouses often re-
mains. Often the nondrinking spouse feels threatened
and insecure at suddenly being confronted with a dif-
ferent, more assertive person. This, together with her
understandable anger, may goad him to flee the home.
The child is caught in the middle.
Many treatnieiu modalities encourage the alcoholic
to attend meetings so that he is at any rate spending
as nnich time away from home as he formerly spent
drinking. All his social relations have to be relearned.
This causes a further strain on sixjuse and children
who already sultcred much.
What Can be Done?
.As has already been menlioned .ind is implicit in
the discussion of the childien ol alcoholics, the single,
most important iulluence ou adolescents' drinking pat-
tern is (he atiiiude ol the parents. From among the
clnlcheii (il .dcoholics, "iH";, ol oui future alcoholics
\ull be cleiivccl. Il is ihcrelore juiumlKiit upon each
ami i\er\ one ot us lo esaniiiie oui' attitudes toward
.ikohol and chinking.
.\ie uc clear about the' lole ol alcohol in oiu li\es?
Cm ue clistiiii.;uish lien\ccii soci.il chinking, the use of
alcohol in luoclc'iatiou and lieavy chinking? Do \\c ha\e
an escape nice hauisiii? Do we ha\e a rigid or sensible
.utitiide lou.ucl the .ilcoliolic? Do ue have a perinis-
si\e attitude toward ch unkenncss;-' Do we provide non-
.ckoholic chinks at a p.ulN?
.\ jirofessional colleague has a \erv rigid attitude
low.irds akoholisui. He has an alcoholic brother who
is a constant source ol eiiibarrassment lo him. .\s a re-
sult, he is unable lo loleiatc anv alcoholics. This man
is (ilniously unable to either advise his own children
or Ileal adolescents who drink or come from an alco-
holic family. Neither is ihe man who is overly per-
iiiissi\e in his altitude. .V happy medium is best; a view
based on a mature outlook on the realities ot lite.
Some ol the concliiions ol uonu.il social drinking
need lo be emuneialed. One is that thinking should
be associiied with eating. .\ gocKl way to start one's
child oil the light ti.ick is by olleiing an occasional
glass 1)1 wine willi a iiie.il. I he laws 111 some states
2k]
,iie grossly iinie.ilislir in not allowing ^ikohol scrxcil
with meals, or food where alcohol is oflcrcd.
The aclolescenls with drinking problems generally
start drinking lalor and awav from home. Therefore,
it is advisable for ])aients to provide alcohol in the
home where its tontrolled use lan be learned. Parents
shoidd present the lestiirlioiis on its use in terms o(
meaningful consec|iieiiic and tieat the moderate use of
alcohol as accejMable: being neither ten) prohibitivelv
uncompromising in attitude nor too tolerant.
Too frcqiientlv. we adults will tolerate dnnikcn
behavior as being amusing, latlier than seeing it foi
what it may be: a svmptom of developing alcoholism.
We must be very clear to oin adolescents that this is
not tolerable beha\ior, that this is not the aim in
drinking.
Some parents feel that if ilu\ o, their children
drink just beer, ilierc is little cause loi any concerir
^Vhat they don't reali7c is ih.it a can ol beer is ec|ui\
alent to a shot of whiskey. I luic is no such thing as
drinking "just beet."
These arc some of ilu factois to be considered in
examining our own altitudes towards alcohol which
are consciously or tuiconsc iouslv transmitted to out
children for better or woise. We do best if we con
sciously make an elhiit to leach oiu chilclien the pat-
terns of social di inking, jirst as we tiy to teach them
general social Ijeluuior.
One last factor has to be examined in any discussion
on adolescence, and that is the so-called "generation
gap." In this generally transient, ever-changing societv
of today, many adults are \eiy ainbi\ alent towards
adolescents. They are seen as moie aware and more
knowledgeable than their parents' generation. How
are we adults to treat them if we can't understand
thein? And too frequently, we are ready to believe the
worst about them, as we mentioned, not giving thein
any credit for their innate good sense. If we look for
evil, we will generally find evil.
When Maryland lowered its drinking age to 18, it
developed that almost no bars would serve 18-year-olds.
Why? Certainly foremost among the reasons is that
they are considered a rowdy, uncontrollable bunch.
We must be fair to them, treat thein as the emerging
: dults they are. Above all, we must be honest with
I lem. This is particularly true in trying to convey
■ icial drinking patterns. It does little good to frown
( 1 drunken behavior verbally if one overindulges
' neself.
Let us not overreact. All adolescents will probably
rink too much or unwisely at one time or another
his is the time for empathy and understanding, not
< lastisement and recrimination.
ess is nuich stiongci. It is the alcoholism that is recog-
in'/ed as a disease and the alcoholic in most cases ex-
hibits the most overt malfunctioning.
/\.'\ concenliates entirely on the sobriety of the al-
coholic. .M.inon .ind Alateen were formed many years
later, and separates the si>ouse and the child from the
pain cati.sed by the alcoholic and do not examine the
pathology ol the spouse or children themselves.
Why. however, do the daughters of male alcoholics
ha\e six times the chance of marrying a prospective
alcoholic than do the daughters of non-alcoholics? 'Why
do many spouses, consciously or luiconsciously help
their alcoholic return to his or her drinking? Why is
the di\oice r.ite higher after the alcoholic recovers?
Olniotish, the drinking alcoholic has a place in his
lamily. \ihich is upset b\ his attempt at sobriety. Thus
he Ol she will licc|ueiitly be goaded into drinking
.igain, «li(n the dilleient family structure threatens
the iioncli inking spouse. In other words, the drinking
niembei ol the l,iinil\ is not the only cause of what
might be c.clleil llu alcoholic's lamily pathology.
I heicloie, to Ileal the alcoholic without at the same
time lie.iling the family is self-deleating. There is no
doubt that as the familial iiattern of interaction im-
proyes, all members beneht, including the alcoholic.
I his has been shown in lamily therapy of different
Ol ieiUalions, M\ own ex|)eiience lies in treating 60
families with .i combination of Virginia .Satir's con-
joint lainib therapy and Eric Heme's transactional
analysis.
1 he alcoholic, in the majority of the cases, dropped
out of therapy alter one or two sessions, most probably
because he was not permitted to come intoxicated, and
also was the target of anger and frustration in these
sessions. The family structure changed dramatically
alter the alcoholism problem was not the center of at-
tention anymore and the other members started look-
ing at their own roles within the family.
It usually took the alcoholic between four to eight
months to join the family sessions sober. The return to
drinking, in comparison to other treatment modalities
was low (40%) and the divorce rate smaller, even after
four years. Aside froiti that, the anxiety level of the
spouses decreased markedly. They were better able to
cope with problems. The adolescent's behavior im-
proved in school and in the family. Their acting-out
behavior decreased noticeably.
The findings of Murray Bower in Washington, who
uses the family systems theory as a basis for family
therapy, were very similar, as were those of 'Vincent D.
Pisani, who developed his own theory which he calls
"Familization."-'-^
As has been pointed out, if one parent in a family
i ■ an alcoliolic, the adolescent children are in need of
s lecial care and treatment. Hence, the whole family, of
t le alcoholic should be treated. However, that is easier
said than done. As we have seen, denial is one of the
symptoms of the disease of alcoholism. Yet the denial
of the family ahwut being involved in the disease proc-
The psychiatric orientation of the therapist does not
seem to be important in assessing the results. All these
approadies have the following in common: First, the
family's anxiety is defused by ventilation of the frus-
tration and anger of the members present. Secondly,
communication between the members of the family is
reestablished to the point that they feel free to discuss
June 1975 MD State Med. J. 67
242
:iu\ <>i llicii- IcL-liiins, lliiiclK, ilu- mlr cil cm h ol ilic
iiK'nibiis and lIu drsliiu livciicss oi ilic i nnsii ik i Im'
iiess 1)1 ilusc lilies .iic uiumcicd
I'in.dK, tlu- l,iiinl\ uoiks id ( li.nij;u dcsli lu li\c |i,il
it'iiis. As .1 icMill. iIh scII-|)ci |icliialiin;, sic ions ( m !<■ nl
s])ii,illiiiL; |)alli()liii;\ is liMikcn. Ilu iionliiiii iiniiiin;
ihcihIkt ol tlic laiiiiK (olun ilic .il( oliolii ) lui |iiiij;(i
fits in and IccK isolated.
litis lic(|ncnll) bcionus {laiiiliil lo llic |Minil ul his
I)e(oniinti williiif; lo ni\e up di inking; lo imkc ,it;aiii
enter the lamiK (iide. li((|U(nil\ . llic inosi sialilc
ilicllllK'l ol the (aind\. he H ,i |>.ii(nl oi one ol the
older (liildieii. is ihe doininanl I.h loi in ihe iin|iio\e
iiient ol the lamilv ssslem anil a jjieat liel|i in ihe
tlieiapv.
Conclusion
11 ue, ,is a people. In lo leai h oni adolisienis
moderate ihinkini; liahits in ihe home and, luilhii
more, see to it ih.il help is pro\ided in ihe (hilduii ol
alcoholii s. we will t;o a ioni; wa\ towards (iiibini; ihe
disease ol .dcoholisni in Inline j^enei.itioiis.
References
1 U^Hiiii. M. .iliil liilHS. Mil; riiii.im' DMnkiiin \i« \..ik
1.1,1
ml Aliohi.l. A
llii M.iiisUs
. (,. ;ill(l tli.ilnniKl, ].. (Iiilili
Mlo|>.iRnt,ll SiMih III (.l^l^Kii". \i'liiii
lioncr\ OIFkc, I.iiihIi.ii, |m7'J.
S. Maclilds. (■!.. .mil MiCall. lit.: DunUiiK Ahhiiik' inn
agcrs: A .StKiiiloKii al liiln|inl.iliiin ul Almlml Isi- li\ llicii
SthodI Sliiilcnls. Miinii)»ia|.h Nii. Ii.in Ni_« Unnisnuk, \.«
Jcrscv. Ringers Cciilcr ii( Aliiihol Simlics, lOlil
4. Sjn Maico Ciiuiuy I)i|i.irinRin ol I'ulila Hcilih iiiil Wil
fare. .Surveillance iil SiiiiU Diiig 'sc. I'.I7:!, .s.iii Maun
Clouiuy. C:.\.
r,. ChapiK-ll. M.\ , el .il: I se "f .Mii.liolii lieici.iKes .\moiiu
High .Sdiiiiil .Sniileiilv. Mrs. J S. Slu|.|i.inl tiMiiul.llioll. Nevi
York, IH.".:i.
n.oiis. |..liii ,i,iil Sl.iM. Il.iuii: leeiiagels and ,S<lli«i|-. A
1)1 VI li)|, 111,1, 1,, I siimK ,1, (,l.is^,,u. \i,l,iiiie II. Iter M.iji-slvs
SI, ,lr,s OIIkc. |ii;'J
Asi„,i. \ \\1 liciagc Diinking neliavior. t.,iki-l>cail l.ii.
M,-il\. Ihiiniiei li.n. Oiilarin, \iliiiiliiin Rcscaith Iciuiula-
l,i.„. I, ,1,,. |il7L>
ll.mrs .mil Sl.in% ( )|i (,,1
D.iMis .mil SI. I, IV ()|,. ( il
D.iMis .mil SI.,,, v. IM III Mii.liiilii lUvci.igis lis HiRh
S,hi.,.l Slulllll^ 1,1 N.iss.iii (iiimlv Rel.,11,1 to I'.ircillal I'cr
lll,^MMI,|.^ \lls |S Sl I C| ,| l.l 1 1 1 I I .1 1 1,1 1.1 II, .1 , , NcU York, IW,},
riil.hi Ml. MIS l'.m,|il,lil No I'lM. I hi' \r«' .\li., holies: 1 eei,.
■iKii- hv lulls S.ill ,,.(!,, I'17'i
M.iililox, (.1 ,mil \li(,.,ll. lt(. 1)111, kmii Milling 1 ecii.igcrs.
RiUi;.! , (1,1 1 M.ohol Siiiihis. I'lihliialioiis Divisiiin.
\i u l',,U,ls»|,k. \|. ||||,I
II, IS niinlliii.il sln.lv .on.lmliil In llie \cw |erscy police at
,lii ( h.ils liiiilui' ■■111,1 I Ihi- Nivv \nik liilHs, May
r, .III. I II. I'lhl.
\li.,li..l .1,1.1 lli.illli N..US N.ilion.il (.k.ilmghoilsefoi .M.ohol
liil<.,ii,.il I il.i \.iii,.ii.il liisiiiiiu: on \ki>hol .\Imisc and
MinhoIlM,,. Ol I I'l7!
/vl.m,. Kiili.ii.l l)v, i.iiipli.iMs on Mioliol Mav Ik- Gosling
I ivis I'l.h.r ( 1,.. I Volni.i.- Ml. \iiiiil.ir 1. fan.. M174.
I', I,, l)( Silmiii.,,. Sll \s lepoiuil 1,1 Ihe loiirnal,
\ 1 RiM.,1,1, l,,im.l.ilioi,. loionlo. |, 2. Dei I. 1973.
llos \\t..\ |i,is, 1, !• Sill, his of .\|,|,io\ilii.ilelv 500
(111!, Inn wilh liih.ivioi I'lolileiiis ii, the liallilnoic area.
|il7-J III71 I ll|,i,l,lisliiil
lliiil
|oii,s, \l I I', ISO,,., I, IV ( i.,,elaus a, 111 .\,ileie<lenls of llrink-
iiig in \\oi„en. |..uiii,il ol ( oiisnlling and Clinical Psy-
ihologv. \.,l. ■», I |.|> 111 li'l. ri71.
loiies. M ( I'liM.n.ihlv \ii,eirikiils .mil C.nelalcs of Drink-
ing 111 Woiiiiii [oi ol (onsiilnng and Cliniail Psy-
(hologv. \i.l 11, I, |.|, L' i'J. I'KiH
ii,.u. I. M.iii.iv I lie t SI- of l.miilv I hii.i|iv in Clinical Prac-
hie ( oii.|.ielir,,s,ve I'svi hi.it, v . 7.;M'i. I'Hili.
I'ls.m,. y 11 R.ilion.ile lor llir Pli.irss of Familization,
l',.s, nle.l .,1 Ihe 1 nil 1 11.11 ioli.il Inslimie on .\lrohol and Drug
Dei.rnikn.e Seville. Spain. 1972. fl
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2^13
alcoholism section
A service of the Subcommittee on Alcoholism
of the Medical and Chirurglcal Faculty
Does the Type of Treatment
i^lake a Difference?
WALLACE MANDELL, PhD, MPH
Professor
Department of Mental Hygiene
School of Hygiene and Public Health
The Johns Hopkins University
Baltimore, MD 21205.
Send reprint and information requests to Dr. Mandell.
•
The following paper, presented to the American
Medical Society on Alcoholism Second Annual Meet-
ing held at the Johns Hopkins University School of
Hygiene and Public Health in 1971, is of great interest
to all physicians because it raises fundamental ques-
tions applicable to the treatment of disease in general.
In addition, specifically, it continues to provoke those
of us who specialize in alcoholism to be concerned with
goals of treatment and with evaluating the efficacy of
our efforts.
MAXWELL N. WEISMAN. MD
Past President, American
Medical Society on Alcoholism
Director. Division of Alcoholism
Control, State Department of
Health and Mental Hygiene
Introduction
In 1942, Voegtlin and Lemere' reported a remark-
able reluctance on the part of English-speaking physi-
cians to submit their treatment programs for alcoholics
to evaluation. Bowman and Jellinek^ found that only
seven studies with acceptable research designs had
been carried out up until then. In 1965, Pattison'
and Hill and Blane in 1967,* in separate articles, report
no more than 20 follow-up studies available with
quantitative data about outcome in the English lan-
guage.
These studies rarely had methodologies which would
be acceptable by contemporary standards. In addition,
the methods employed are so different that it is diffi-
cult to compare their findings. During the years from
1960 to 1970, few methodologically-sound studies have
been added to the literature despite excellent articles
published periodically reviewing the faults of previ-
ous studies and pointing clearly to what needs to be
done in the way of research methodology. This sug-
gests that there are unresolved problems in providing
treatment and evaluating it.
The present paper is based on a review of the
evniuative studies published in the English language
betueen I960 and 1970. It is directed at clarifying the
issues involved in developing effective treatment re-
gimes.
80 Md. Slate Med. J. March 197S 245
Theme of Research
During the period reviewed, the basic theme of re-
search can be summarized in the question "Does treat-
ment make a difference?" Fleming,^ in 1937, wrote,
"Practically every fomn of therapeutic approach has
been successful— all have their coterie of enthusiastic ad-
vocates, all are fanatically intolerant of any approach
but their own and doubtless all may have a place in
a rational therapy of alcoholism."
A'7slinence as a Criterion
In order to evaluate the efficacy of any treatment it
can be compared with an untreated control group. Dur-
ing the 10-year period under study, 12 untreated con-
trol groups' abstinence or improved control over drink-
ing rates were reported. The range of improvement was
from 4% to 47%. This seems to be an unusual range.
Upon further examination, it turns out that abstinence
does not mean the same thing to different authors.
In some cases abstinence means "at the time of the
follow-up" and for others it means during the entire
follow-up period. Ludwig has nicely demonstrated that
at the time of a one-year follcv-up, 40% were absti-
nent but only 20% had been abstinent the entire year.
Since most authors are not specific in terms of defini-
tions of abstinence, it is difficult to compare their
data. The studies report untreated patients as having
an abstinence rate for a one-year follow-up ranging
between 20% to 47%.
Who Can Be Studied
Voluntarily hospitalized patients in State Psychiatric
and VA Hospitals have been studied along with out-
patients at clinics as well zs individuals appearing be-
fore the courts or in jail. Surprisingly, even among pa-
tients admitted voluntarily to treatment, up to 25%
refuse it. Authors are not specific as to whether these
individuals should be considered as failures in treat-
ment. This procedure would reduce the percentage re-
ported abstinent in the treatment group.
Some researchers believe that certain individuals
should be excluded from treatment, as for example the
psychotic, the mentally defective and the brain dam-
aged. This seems reasonable. On the other hand, j>re-
cluding less intelligent, socially deteriorated or lower
class subjects might inflate the improvement rates.
In fact, several studies have indicated that these
factors are significantly correlated with improvement
rates with or without treatment. If the control group
also meets these criteria, the treatment regime might
still be given a fair test, even though generalizations
would have to be restricted.
Alcoholic patients seem to drop out from treatment
in considerable numbers. Kissin^ has shown that if the
dropouts are considered as being in treatment, success
rates are cut in half.
Other Developments
Kissin, et al^ have made a contribution by studying
the differences in improvement rates among placebo-
treated patients during the course of eight years of
reseaich. The rate of improvement does vary and this
seems to be related to the proportion of Negroes in the
group. Perhaps as interesting is the fact that within any
Table 1
Author
McCance
1969
Treatment
Facility
Psychiatric
Hosp.
#
+ Type of Alcoholic
Patient
Voluntary or
Involuntary
140 volunteers
for treatment
out of 193
Follow-up Time
— Criterion
Type of
Tieatmenl
Gp. therapy
Aversion
Ou
Pis.
43%
53%
come
Control
47%
193
drinking out of
control
Abstinence
1 yr.
75
drinking out of
control
54 volunteers
for treatment
Abstinence
1 yr.
Farrar
1968
State Went.
Hosp.
12
Abstinence
1 yr.
1 trial succinal
choline chloride
22%
Kurland
1968
State Hosp.
378
white male
Abstinent
1 yr.
hospitalization
22%
Blake
1967
State Hosp.
52
inpatient
alcoholics
1 yr.
Abstinent
relaxation
aversion
46%
23%
Vallance
State Hosp.
68
males
2 yr.
Abstinent
3.2 weeks
first aid
4%
Rathod
1966
State Hosp.
106
excluded
"unsuitables"
volunteers
2 yr.
Abstinent
Gp. therapy
44%
Pemberton
1967
Psych. Hosp.
50/10 yr. male
drinkers hi ses
50/10 yr. female
drinkers hi ses
1.2 yr.
Abstinent
1.2 yr.
42%
22%
Ludwig
196Q
State Hosp.
176
inpts.
Abstinent at
1 yr.
(during yr. 80%
have drink)
LSD
Disulferam
Hypnosis
40%
40%
Ritson
1968
Inpt. & OPD
100
no socially
deteriorated,
volunteers
6 mos.
Abstinent
18%
Moore
1960
VA Hosp.
Open ward
100
Voluntary
Decrease in
drinking 1/2 mo.
after discharge
162 days on
+ OP clinic
16%
26%
Ferneau
1969
VA Hosp.
144
Voluntary
Abstinent
6 months
Psychotherapy
Disulferam
35%
Millers
1968
VA Hosp.
201
Voluntary
75% stay on
ward 90 days
Holllster
1969
VA Hosp.
72
Voluntary
Abstinent
6 mos.
LSD
Amphetamine
22%
22%
Meyerson
1961
Jail
49
female alcoholic
psychopaths
Involuntary
1 yr. return
to clinic
Supportive
interviews
36%
Mindlln
1960
Jail or
OP Clinic
100
skid row males
Involuntary
3 mos. to 3 yrs.
some improve-
ment
Clinic gp -1-
workhouse
32%
Meyerson
1966
Half-way
house
101
indigent
alcoholics
Ditman
1967
Probation
241
Involuntary
Rearrest
Clinic
AA
32%
31%
44%
Miller
1942
Municipal Ct.
Clinic
513
Promised re-
duction of
sentence
9 months
rearrest
Amphetamine
Sulphate -t-
Phenobarb
79%
58%
Kendell
1966
No treat.
43
men
Former treat-
ed pts.
6.7 yrs.
Abstinent or
normal drinking
Sought
32%
25%
Marcti 1»75 Md. State Med. J. 81
246
Table I (Continued)
Treatment
# + Type of Alcoholic Voluntary or Follow-up Time
Type of
Outcome
Author
Kissin
Facility
OPD
Patient Involuntary + Criterion
Treatment
Meprobamate
Pts.
16%
Control
15%
159 pts., 75 controls Volunteer for 6 mos. absti-
1968
alcohol clinic nence or dimin-
ution in drinking
& social im-
provement
& benactyzine
g^i exp. #; 95 controls
Isocarboxacid
Chlordiazepoxide
8%
11%
15%
94)
gg exp. # ; 1 00 controls
Emylcamate
Amitriptyline
8%
5%
57 pts.
Imipramine &
chlordiazepoxide
20%
55 pts.
Chlordiazepoxide
Meprobamate &
21%
22 pts.; 27 controls
promaxine
hydrochloride
6%
11%
28 pts.; 30 controls
Amitriptyline
9%
10%
180 pts.
Gp. psychotherapy
20%
4%
184 pts.
Drug
17%
Rehab.
20%
Drug more than
10 visits
34%
Psychotherapy more
than 10 visits
40%
Kendell
OPD
99 pts. Voluntary (con- 4 yrs.
32%
24%
1966
trol not treated
9
died
3 died
but suitable)
4 suicide
1 suic.
Ditman
OPD
116 pts.; 79 controls Voluntary 3 weeks return
Imipramine
42%
57%
rate
fhlordazine
22%
21%
diethyl proprion
28%
42%
chlordiazepoxide
20%
10%
year all of the treated groups had the same rate of im-
provement.
This rate will vary from year to year but will not be
different from the control group of that year. These
authors suggest that norms for improvement are de-
veloped during the course of a treatment program by
patients and these norms influence success rate.
Does the Type of Treatment
Make a Difference?
The evidence in relation to the following treat-
ments has been examined for six months and/or one
year abstinence rates: hypnosis, group psychotherapy
aversion treatment, relaxation, hospitalization, outpa
tient clinic treatment, jailing, probation and the fol
lowing chemicals singly and/or in combination: sue
cinal chlorine chloride, disulferam, LSD, amphetamine
imipramine, thiordazine, diethyl proprion chlordiaze-
poxide, meprobamate, benactyzine, promazine hydro-
chloride, isocarboxazid, chlordiazepoxide, emylcamate
and amitriptyline.
When abstinence rates are compared for treatment
and control groups in those studies, where they are
available, there is no statistically significant difference.
When treatments are compared with each other in
roughly similar settings there is no statistically signifi-
cant difference. What seems to make the difference is
selecting motivated, bright patients from upper socio-
economic status who are not deteriorated, psychotic or
brain-damaged. The abstinence rate with such pro-
cedures can be raised to 44% in the US and England,
but a comparable group without treatment in England
had a one-year abstinence rate of 47%.
e: Md. SlJle Med, J. Mjr<K 1975
Ihl
There is always a great temptation to explain a find-
ing of no-difference. Scientifically, there is no rational
test for the \eracity of such explanations of no differ-
ence. In the absence of knowledge and with no possi-
bility of being dispro\en, I will venture some inter-
pretations as to why there are no differences between
treatment and control groups.
Pattison pointed out in 1966^ that a single treatment
applied to all types of alcoholics is unlikely to prove
very efficient. The treatment might be effective with
a particular kind of alcoholic. The treatment effect
would be diluted in a study wih the wrong kind of sub-
jects. Similarly, treatment programs consisting of a
little bit of e\erything may not provide enough of
what any one type of alcoholic needs and therefore
also yield a low abstinence rate.
•
Alcoholism may be a multiply-caused condition in
which various factors contribute to the final appear-
ance of the clinical condition. In such conditions sug-
gestion, or, as Kissin's group said, shared norms about
impro\ement may be the important factor. This may
be discouraging from the researcher's point of view
but encouraging from the clinician's if he can influ-
ence the group's expectation of success.
It seems possible that individual and group estab-
lishment of norms may be effective. One bit of data
prompts me to suggest that pills of some kind are not
all bad. In the Brooklyn studies it seems that patients
given pills are more likely to come back for treatment.
If types of alcoholics may benefit differently from
different treatments, it might be helpful to point to-
ward a practical clinician's typology. Reviewing the
literature has suggested that it is the prealcoholic symp-
toms that may be most useful in developing a treat-
ment plan, i.e., anxiety, depression and sociopsycholo-
gical incompetency. Withdrawal of alcohol may leave
the individual with his prior problems. There are now
available treatments for each of these.
I would like to end on a serendipitous note of op-
timism. Abstinence may be the wrong criterion with
which to judge treatment outcomes.
Kendell' followed 99 voluntary patients for four
years. There was no statistically significant difference
between treated and untreated cases in abstinence or
improvement in drinking pattern. However, 13 of the
untreated died, including four suicides, in the four-
year period, while only four of the treated died, in-
cluding one suicide. This is a remarkable finding.
Treatment may be more effective in keeping the alco-
holic alive than in producing abstinence.
My speculation is that the alcoholic is an individ-
ual who has made a sick adjustment around the use
of alcohol. He comes for treatment when his drinking
has been disrupted eillier socially or because of physical
illness. During such a period, he must face previously
disturbing problems without his accustomed physiolo-
gical and psxchological supports. Treatment lielps him
manage the disruption. By doing this, it gives him time
to build new patterns. Unless he is helped, he con-
tinues in a disorganized and depressed condition until
it is terminated by death or re\ersion to alcohol.
References
1. Voegtlin, W.L. and Lemere, T.: The Treatment of Alcohol
Addiction: A Re\ieu- of the Literature. Quart. J. Smd. Ale.
2:71;-80.1, l<)-!2.
2. Bowman. K.M. and Jellinek, E.M.: Alcohol Addiction and its
Trealmem, Quart. J. Stud. Ale. 2:98-176, 1941.
3. Pattison, E.M.: A. Critique of Alcoholism Treatment Con
ccpts with Special Reference to Abstinence, Quart. J. Stud.
.\lc. 27, 49-71, 1966.
4. Hill. M.J. and Blane, H.T.: Evaluation of Psychotherapy with
.Alcoholics, Quart. J. Stud. Ale. 28, 76-104, 1967.
5. Fleming. R.: Management of Chronic Alcoholism in England,
Scandinavia and Central Europe, New Eng. J. of Med. 216,
279-289, 1937.
6. Kissin, B. et. al.: Drug and Placebo Responses in Chronic
Alcoholics, Psjchiatric Research Reports, 24:44-60, March,
1968.
7. Kendell, R.E.: Normal Drinking in Former .Mcoholics, Quart.
J. Stud. Ale. 26, 595-605, 1965. □
2i»8
POPULATION ASSOCIATION OF AMERICA
COMMITTEE ON POPULATION STATISTICS
Testimony on behalf of the Population Association of America will be presented
to the President's Biomedical Research Panel by Jeanne Clare Ridley, Ph.D.
Dr. Ridley is a Professor of Sociology and Demography at Georgetown University
and will appear in her capacity as Chairman of the Committee on Population
Statistics of the Population Association of America.
The Population Association of America is devoted to promoting research with
respect to problems related to human populations both in their quantitative
and qualitative aspects. The Association has 2504 members. Its members
pursue a broad range of specific interests connected with various aspects of
the study of human populations. The members are drawn from a variety of
disciplines including not only demography and other behavioral sciences such
as sociology, economics and psychology but medicine, public health, and
biology.
The Population Association welcomes the concern of the panel with issues re-
lating to policies concerning the subject, content, organization and operation
of behavioral research programs of the federal government relating to human
populations. The Association appreciates this opportunity to express its
views on these topics.
This statement is designed to provide a brief perspective for viewing the
significance of behavioral research on human populations and to suggest to the
Panel members certain improvements in the content and organization of population
research conducted and sponsored by the federal government. We intend to draw
upon many of the excellent recommendations made recently by the Commission on
Population Growth and the American Future. By doing so we wish to emphasize
to this Panel that these recommendations have yet to be considered in any
detail or acted upon within the executive and legislative branches of the
federal government. These recommendations were made by a distinguished group
of American citizens supported by a highly competent staff who carefully considered
the problems of population over a two year period.
SIGNIFICANCE OF BEHAVIORAL RESEARCH ON
HUMAN POPULATIONS
Since the 1940' s the United States has been experiencing profound demographic
changes. These changes have had a major impact on population composition and
rates of population growth. For instance, in 1940 there were slightly more
than 12 million women aged 15 to 24. By 1970 the number had grown to almost
18 million and currently (1975) the number is estimated to be almost 21 million.
Thus, in a period of only 35 years the number of young women in the American
population has increased approximately by 75 percent. Similar increases have
2^*9
occurred among males in this age group. As is well known, these increases
in yDung people have severely strained our educational and health resources
and are having a major impact on our labor force and economy.
There also have been the sharp changes in birth rates since the 1940' s.
In the 1940' s and 1950' s after a long term decline beginning in the 19th
century our birth rate rose to a peak of 27 per 1000 in 1947 and for a
period of 10 years continued at a level of approximately 25 per 1000. At the
end of the 1950' s, however, the U.S. birth rate began to decline again and
today is at an historic low of approximately 15 per 1000.
Although we now have a birth rate that implies eventual population stability,
the American population will continue to grow. Assuming that American birth
rate remains at its current low level and couples have only an average of two
children, the population will continue to increase because the number of
young people entering the childbearing ages will be growing. This momentum
of population growth is dramatically portrayed in Figure 2.2 which has been
reproduced from the final report of the Commission on Population Growth and
the American Future.
As the Commission stated, however, "our population has a potential for further
growth greater than that of almost any other advanced country". The major
reason for this is that the number of young people entering the childbearing
ages will continue to grow. Moreover, we can not be at all certain whether
American reproductive behavior will continue to exhibit the restraint of
recent years. If instead of an average family size of two children, average
family size were to be three children, another dramatic spurt in population
growth greater than that of the baby boom period of the 1940' s and 1950' s
could again occur. Figure 2.3, reproduced from the Population Commission's
report, shows the difference that an average family size of three children
could make as opposed to an average family size of two children in the size
of the total population.
As yet we are not sure of all the reasons why the baby boom occurred. Nor do
we know the reasons for the current low levels of fertility. We do know that
a dramatic shift in birth expectations has occurred in recent years among young
women entering the childbearing ages. In 1965, married women 18 to 24 years
of age reported that they expected an average of 3.1 children. In 1972 married
women in this age group reported that they expected only an average of 2.3
children. By 1974 the average expected was 2.2 children. We are also uncertain
as to the reasons for the delay in marriage and thus in the initiation of
childbearing that has been occurring among young women. For example, in 1960
72 percent of young women aged 20 to 24 had already married. But in 1974 only
62 percent had done so. Although current fertility is at a low level, it must
be stressed that there remain pockets of exceedingly high fertility in the
American population. Moreover, even if the United States should achieve stability
in population size, it cannot overlook the high rates of growth occurring in
the developing countries. Much of the work that needs to be done on high fertility
groups in this country would have direct applicability to the problems of high
fertility in developing countries.
250
} igure 2 2 The Momentum of Population Growth
Millions
bO
20
An average of 2 children per family would slow population
growth, but would not stop it soon because the number
of people of child bearing age Is increasing . .
1980
2000
251
Population developments are the consequences of biological, social, economic
and psychological factors. Birth rates go up and down as individual couples
make decisions to have or not to have children. Death rates and the length
of life are sharply conditioned by the economic and social circumstances
that affect the individual's ability to secure adequate medical care and to
avoid preconditions that lead to early morbidity and death. Changes in family
patterns, rising divorce rates and differences in the mortality of men and
women are creating an increasing number of older persons living alone or in
institutions and requiring the development of special programs. Migration of
people from rural to urban places or suburban areas, and between central city
and its suburbs changes the patterns of life in the areas from which migrants
go and those to which they come. These in turn affect birth rates, mortality
rates, and the need for a variety of social services.
The dramatic changes in fertility rates in this country since the end of World
War II illustrate the importance of social and economic factors that influence
the individual decisions involved. The decline in fertility rates, following
the post-war upturn in birth rates, began in 1957 before the pill or the lUD
were widely accepted. Contraceptives are a means to the desired end, namely
the family size deemed to be best by the individual or couple. Perfect contra-
ception applied by families who consistently desire six children would lead to
very rapid rates of population growth. On the other hand, perfect contraception
applied by families that consistently want two children would practically stabilize
population numbers, after the effects of the current irregular age structure
have been "worked off" in this country. Moreover, recent developments in the
acceptability of abortion and sterilization raise questions as to their effects
on fertility. There are also considerable uncertainties relating to the short
and long term psychological and social consequences as well as the medical
consequences for individuals employing these methods.
Social factors bear on all phases of biological behavior relating to birth and
death. Marital status has a significant relation to the welfare of children.
Despite changing attitudes toward children born out of wedlock, they are exposed
to greater risks of mental handicaps and infant death than children born to
parents in conventional family settings. Social status, age at marriage and at
conception, color, race or membership in minority groups, education of the
parents, urban or rural residence, all have important bearings on the degree
of prenatal care and such matters as birth weight, fetal and child mortality,
and intelligence and congenital abnormalities. Birth order and size of family
are significantly related - the risks for the first child are different from
those of the second or third child. These in turn are different from those
which apply to higher parity children.
The conditions favorable to child health and development are not equally distributed
throughout the society. Family income in the absence of one parent is an
important element, as is the ability to provide adequate nutrition. Moreover,
attitudes toward age at marriage, family size, illegitimacy, and the satisfactions
25'*
that parents derive from having children are all significant in determining
levels of reproduction. In a country like the United States that is
committed to freedom of choice in matters of human reproduction, a knowledge
of the conditions that affect the application of known contraceptive
techniques contributes not only to an understanding of prevailing trends
but to the promotion of the effective use of contraceptives.
There are major differences in mortality among social groupings of the
country. Occupation, education, income, residence in central city, suburb,
or rural areas; residence in the North Central region of the country as
compared with the South, West, or Northeast; membership in certain ethnic
minorities, all have a significant bearing on mortality rates and on the
length of life. The growing disparity in the length of life between males
and females in the United States undoiibtedly is largely socially conditioned.
Recent declines in infant mortality have been as much the result of changes
in the age at which women begin having children and the size of their
completed families as improvements in obstetrical care.
RECOMMENDATIONS
The foregoing discussion while intended to highlight the large number of
factors influencing population growth rates and the spatial and social
distributional aspects of the American population suggests something
of the priorities and content of needed population research. The Commission
on Population Growth and the American Future made a number of recommendations
that bear directly on the charges to this Panel, This section will discuss
many of these recommendations. In addition, particular recommendations of the
Population Association will be presented. Since we intend to discuss here
only those recommendations of the Commission we consider most urgent, we
have reproduced in Appendix A all the recommendations of the Commission relating
to governmental and non-governmental population research and organization.
The Population Association believes that each of these recommendations merits
serious consideration.
Regarding data needs, the Commission recommended a number of specific im-
provements to strengthen the basic statistical and research programs within
the federal government. Of particular importance is the need for the
federal statistical agencies to improve the release of and availability of
data on a more timely basis. Not only is there a need for the more timely
release of basic vital registration data on births, deaths, marriage and
divorce collected by the National Center for Health Statistics but a need for
a faster release of data collected in the many specialized governmental
surveys. In connection with more timely data, the Commission pointed out the
increasing need for a Mid-Decade Census of population. A Mid-Decade Census
would provide a much firmer basis for improving the work of the Bureau of
Census on intercensal estimates for states and local areas. The demand for
current population estimates has been increased tremendously by the revenue sharing
and other recent legislation of the federal government. In addition, state
255
and local governments have increasingly recognized the need for more adequate
planning for future health, educational and other social services. As
previously pointed out, the continuing redistribution of the American
population as a result of high rates of internal migration quickly outdates
the results of the decennial censuses.
The Commission also noted the need for improvements in the coverage of the
Current Population Survey by enlarging samples to permit the study of
demographic trends in special population groups, particularly minorities,
the development of comprehensive immigration and emigration statistics, and
statistics regarding aliens resident in this country. Further attention should
also be directed to improving the quality of the demographic data collected
by the federal government. Without such developments, attempts by governmental
and non-governmental groups to evaluate the impact of governmental programs
and to plan adequately for the future needs of the American population will
be seriously hindered.
Explicit or implicit in many of the Commission' s recommendations was a
recognition of the need for more basic analytical studies of demographic data
by governmental statistical agencies for purposes of evaluating the relation-
ships between public policies and programs and population trends. At present,
the statistical agencies of the federal government spend most of their
resources on the collection of data with only a minimal amount of their
resources going into analytical studies. While we applaud recent innovations
within the Bureau of the Census and the National Center for Health Statistics
to increase the number of analytical studies, we note that only increased
funding will make it possible for these agencies to increase their capability
in this area and thus be able to provide better information for policy makers
in the executive and legislative branches of the federal government as well
as in state and local agencies.
Regarding organizational developments needed in the U.S. government the
Commission stated:
The Commission recommends that organizational changes
be undertaken to improve the federal government's
capacity to develop and implement population related
programs; and to evaluate the interaction between public
policies, programs, and population trends.
The need for such a development is an urgent one. Population trends are
clianging rapidly, governmental actions affect the rate of growth of the
population as well as its distribution within the country. But there is no
256
central point in the executive or legislative branches of the federal govern-
ment that consistently evaluates the changes and interrelationships in
population. We believe that it is essential that responsibility for such
work can be clearly established within the executive and legislative branches
of the federal government. We welcome indications that the Subcommittee on
Census and Population of the House Post Office and Civil Service Committee
is presently taking steps to focus such responsibility within "Congress.
With respect to behavioral population research by non-governmental groups the
Commission also made a number of important recommendations. The Commission
recommended "substantial increases in federal funds to be made available for
social and behavioral research related to population growth and distribution,
and for the support of non-governmental population research centers." Since we
feel the detailed discussions by the Commission on the social and behavioral
aspects of population so relevant to the concerns of this Panel, we have
reproduced this discussion in full in Appendix B of this statement.
The main source of governmental funds for behavioral population research con-
ducted by universities and other private research groups is currently from the
Center for Population Research in the National Institutes of Child Health and
Human Development. The mandate to the Center contained in P.L. 91-572 charged
it with supporting research in both the biomedical and behavioral aspects of
population. The Population Association recognizes and supports the significance
of past and future research in biomedical research related to human reproduction
and the development of contraceptives. It would consider very detrimental any
proposals for reductions in federal funds for this area of research. Yet, the
Population Association wishes to stress to this Panel the equal importance of
research in the social and behavioral aspects of population.
In FY 1975 the Center had a budget of $84 million but only $7 million went to
support behavioral science research in population and to behavioral science
population research centers. The $7 million was split approximately equally
between grants and contracts. Moreover, only about one-half of the grant
applications that .were approved could be funded. The Population Association
would estimate that at present approximately $20 million is needed by the
Behavioral Science Division of the Center to begin to carry out its mandate
more adequately.
The need for basic support of university population research centers focusing
on behavioral research in population is of utmost importance. In FY
1974 ten centers of population research in universities were supported by the
Center for Population Research. Yet only three of these centers focused
exclusively on behavioral research. One additional center received support
for both biomedical and behavioral research. Biomedical research has
increasingly depended on teams of researchers with a variety of skills and
specialties and access to laboratories adequately equipped with highly technical
instruments. Similarly, behavioral research has increasingly demanded the
issembling of interdisciplinary teams of researchers and the use of advanced
•.echnologies such as high speed computers.
257
To date, the development of research centers has provided an organizational
solution to the increased demands, complexities, and needed continuity of
population research. At present, however , the few population behavioral research
centers that exist are severely constrained by the lack of funds for their
basic support and even, in some instances, their very existence is threatened.
Finally the Population Association wishes to recommend, as the Population
Commission did, the need for funds for the training of students in the social
and behavioral aspects of population. Unlike many disciplines where training
seems to be outstrippinq demand, today behavioral specialists in population
are in short supply.
258
Appendix A
Selected Recommendations of the Commission
on Population Growth and the American Future
Population Statistics ?/'<• Cnmnmihin rcionvnctuls tlial ilu- fcJrral finiTinnicnl iii.tc prampilv and h,<IJIv /,■
and Research sncm^iiirn [he ha^w '^fuli'^tirs luiJ rc^rnnh upon ninth oh ^>'uthl ilt-nini^ijphif . sinhil, ivui
innhiDiu pnhvv must iilliiiialcly dcpciij. In' uupU'Diciiling the Jtillinvin,^ .yictijic iin[>rofciih'i:i-
•It I hat' priii:raiiis.
Vital Statistics /'"' Ctmiiiinuoii tctimimcntli !hal Ihc h'tUunuil Cvnwr fur lltallli Siiiiimh^
Data iiiipritvc Ihc iniuiinc^i uiitl Ihe tjualiiy nj ilala ciillcclcd mlh reaped Iti hirlh,
ilcalh, marriage, and divurcc.
Enumeration of The Ci'nnnn'.itin rcomnncnd-i ihiil Ihc Jcdcral g'"-cinnifni -.iipp'TL even nunc
Special Groups smoitily. the Ccnstn litirctiii\ clh'ff^ l" tinpinrc the ftiniplclfne\s kI tun i citws
eninncrtili'iit. aitfcttillv id iniiitirtiv i:i,itip\. vht'llt' ptipiilalti>ns. and all nnatlathfil
adults, especially males, who tire Ihe lea^l well cuiinled.
IntPrnatlonal The CnninusMtm rctommeiuh thai a task Jfiie he ile^tgihitcl tattler lite leatler\hip
Migration "./ ''"' Olltee n] Manageitteni and lliitlgel in ih-viu- a pr,ii:tain Jnr iht derelttpincnl
iij tDinpreheinn'e iininigralinn aitti eininrallitit uaiiute^. tiiul !ti rei timnieiitl miv. in
\thieh lite reetirds nf lite periothc alien lenniniiittiis •.h.nihl he prtn e^sctl If pi;nide
iiijnrinalinn mt the dislrilnilitni and chaiai leriuit s nj aliens in ihc linilctl Stutes
The Current The Ct>mmis\iitn recninincnds lluil ihe gin-ernineni pniridc snhslaniial iitltiiiitinal
Population siippnri Iti the Ctitrcnl I'lipidalton Siitrey In tntpmee the area idenniieuiinn nl
Survey llm^e iiilcn-iewcd and In pcrinii spetial siiiihc. iiltltzina cnlar,i;etl samples, nj
tlcinniiraphlc Ireiuh in special i!.rniqn nj the ptipulalinn.
Statistical Reporting of Ihe Cninnii^\htit reeninmeiids lite rapul dcveltipntcnl nj cninprehenstve siatisttts nn
Family Planning Services Itiniilv /ilanninx urvu es.
National Survey of The Cninini\\init rcenmmcnds pmeiant siippnri aittt cnnliniied a.leipiaic linantnil
Family Growth sii/'pnrl fnr the I'amilv Crtneih Siirvcv a\ alneisl ihe first ondtlinn fnr crahiaiiitu
the elh; livene\s nl nale null p, ipiilat I, lu ptilii les aitt! pnti^tann
259
DiMiibiition of "/■''<• C<n,ininv.:ii nrnniiii,-ii,ls Ihai ihr i.in.'in u.iiniKvhiK'ii, i.'s s, rk /.. nuixirn
Government Data '''<' I'nl'hi i(\cjiil)ic\s •</ iln- husic Juia by making iJcniiiv-lrcc tapes availahic i
f[S/)i</n;/i/r iccarcli ugiiKias.
Mid-Decade Census '/'"■ Oaiininswn ui,aiiiiuii,l\ ilun ilu- dccciuiial ccnsin he siipplcmcincJ h\
imd-dccadc census I'f llie pupiilalinu.
Statistical Use of . Hie C,„nniissi.-n leenninieiiJs ihul the g.nernnirnt i;he higli pivavv h< ■.ni.lur
Administrative ""' »".'^ '" »/'"/' lejeial adnunisinilne ne.'nis. n.'iahlv ilmse nj ilie Inhn
Records Revenue Serviee an, I Sneial Seeiiniv AJininnDaiinn. (mil J he inade iiwie usejiil Jn
ileieliipiiie sialislual eslinuiles n) Imal pnpiilalhin and infernal niigialiniL
Inteicensal Population Hie ('nnunnsi.in leennnneiuh ilia/ llie gfteiiinieni pr.nide inereased liin.liii
Estimates liu^her pivmrv. and uneleiaied denhpineiu hn all /'haws n] ilie Cen.iis Hiireau
proKiani ha develnping inipnmd mien ensal pnpiilalinn eMiniaies h>i \iaies an
Inealaieas
Social and Behavioral The ('•unnnssiiai reennnneiuh ihai \iih\iaiiiial uiiieases in lederal fiiiuh he ni., '
Research avoilahle Inr sonal and hehari.aal ie\eai,ii lehiled lo p.'pnlali.in nhnvih en-
dislnhiitiiin. and Jill- die siippnii nl iinng.neinnienlal pupiilali'iii researeh ecnl, ,
Research Program in I he Cinniin\\u>ii lei nniinends ilial a leseaieh pn 11:1 am in p.ipidaiion disiiihnii.'i: ■
Population Distribution eUaldislied. prelenihlv niiliin the prnp,<ied Depailinent nj (nnintni,.
I>evel<>ianenl , liinded he a small pereenlage assessment ml jiiiuls appropriated I-
releraiil jederal progianis^
Federal Government ihe C\miini\simi reiommeiuh thai the ledeiul g"eeriinieni Insin the in-leais'
Population Research researi h eapahihues ,<l iis ,>nn agencies in pi mule a enlierent instilittimial stnieiu-
fiainipimingpopiilalioiireseanlL
Support for Ihe Cmninissimi lee.anniends that snppmi j.a iianinig in lii, s.^eial and hihavfi
Professional Training aspects ,./ p,tpidaii,ai he eseinpted In'in ill,- v,n,i,il li.,:e nn iiarnnM hind
penmtiin,^ y,,rernin,-nt ,igen,ies t,i snpp.m pi,,^hinis t,, tiaiii s,i,'iitisis speiiali:in'-
III this lielil.
OigamzatlOnal Ihe C,,iiiniissi,m 1, , .ainnen.ls tlhil . ,1 nniTalh ,n,il , li,nig,'s hi- mid, Hal, n t,, iiiipi,^
Changes l,-deial g,,vermneiil\ ,,ipa,ilv t,> ,le,el,,p ami impleimiit p.'piilalhai-ielate.i pinvam.
ev.ihiale the inlenietl.ai h.tn ,rii piildi, /'.di, i,s, pi, ■gninis. ami p, •pidatl, ai Iniids
Office of Population - Ihe (\,iiiinissi,ai i,;,aimi, n,ls that tli, ,a]>aeilv ■>! the Hepaitnient -'t /hvltii.
AffaiiS, Department of h,lmati,ai ,ni,l H;ilair in ilm p, ,piil:iii,,n tirl.l he siihsiantuillv imieased hi
Health, Education stieiigihening the Dili,,- .■/ I',,pidaii,ai Mpiiis an, I e\pan,ling its stajj in mder t,,
and Welfare niigment its i,,le ,,] leadership within the Ihtiai tin, nt.
260
Growth and
DIstr ihution
National Institute The Cniiiini'isiiii\ ivcuiuiicntls ilic cslahlishinciil. wuliiii llic Xulioiijl Insliliih-s nl
of Population //<■.;///;. <'l a Xaiioinil Insliltilc nf I'u/niLilinn Sucihx-. i.i pioviilc an aJi',/ii,iic
Sciences iiiMiiiinniiul lianicwoik jm iiiiplciiiciiiiiit; a iitcuily cxpdihli\l /'ini;i,iiii nj
pn/iiildihiii rcwun li.
Department of I'lic Coninnwinn rccni,uncihl\ ihal Cuiiyjcw .iJnpi lci;i\hiih>}i lu f'.i.ihlnli a
Community Dcpinniiciu .1/ C'lniiiinnif lh'i\inpii:riil aiul lliiii iliis Depui tiiiciil iiiulriuikc ,1
Development pi.iKnini .</ ic\,uii li mi ilic iiiicnuli,>n\ .1/ /h^piihiih'ii i,v./u7/i ,111. 1 ili\inhuli.iii ,in,l
ihi' pn'i^ivni\ II ULlnlitu\IC)\.
Office of The Ciniiniwinii reeoiiiiiieihh llie ereulioii ,>l an Oltue ,<j T,,pulalinH limwili ami
Population DiMi-ihiiih'N niihin ilie I xeeiinre (JJIne .^l llie I'reuJenI
The CnninuiMiiii reiniiimeiiih ilie ininieJiale ailililnai ot peismiiiel wilh
ileiiiiiiiiiiiihii exjierine In the siall\ nl ihe (nmuil 0/ lei'inani, .\Jn\ei\. ihe
nniiiesiti O'liiieil. ihe O-iiiu il on luifimiinienlal ihuihli. ami ihe Ollne ,>l Si leiu e
and leihnolnKV
Council of The (\>innii\\i(>n reeninineiuh llial Convives approve penJinv legidaiion eUiih-
Social Advisers lishim: ,1 Cuuihil .</ Soeial Ailvneix aiiJ lluii iho. C'oiimil have a\ one of ii\ main
liinelion\ the nionilonm; iij ileinoi;iaphie vaiiahlev
Joint Committee /" ">'^ler 10 proviJe nnpioveil leqnialive nveiMiihl n/ popiihilion iwuey ihe
on Population Comnnwion reeoninieihh ihal Coni;ress a\si,i;n 10 a loinl eoinimllee ie\/ioinihihn
Jorspeeilie leviewol this area.
State Population The Commn'.ioii reeonimentls ihal siale i:overnnienl\. eilher ihr,iiii;h exniini;
Agencies and plannuiK ai;eneie\ 01 ihroii\^h new aKem les Jevoieil 10 lhi\ pinpose. K've i^reaier
Commissions allenlion 10 ihe proltlenn o] popnialion iirowih ami ilniiihiiiioii
Private Efforts and The C'oninuwion reeuinniemh ihal a siihiuinliallv i;reaier eljorl Ionising on
Population Policy pohey-onemeil re\eareh ami aiialvsn oj popiiLiiioii in ihe Unileil Stales he 1 ameil
lonvaiil III roll till appropriate pi ivale lesonrees ami ai^eihiei.
Source: The Commission on Population Growth and the American Future, Final Report:
Population and the American Future. Washington, D.C. U.S. Government
Printing Office. 1972:145-147.
261
REPRODUCTIVE BIOLOGY RESEARCH FOUNDATION
Appendix B
Discussion of Social and Behavioral
Research by the Commission on Population Growth
and the American Future
Social and Behavioral Research
The Center for PopulaUon Research of the Depart-
ment of Health, Education and Welfare has respon-
slhility for promotinc and guiding research in both the
bioniodical aspects of reproduction and contraceptive
development and in the social and behavioral concerns
of population. The Center's role in the first, area is
acknowledfjed and reasonably well-developed. Social
and behavioral research has not been given equal
emphasis This is perhaps because of a bias imposed by
localion of the Center within the National Institutes of
Health. However, since the mandate of I'.L. 91-572
incluilcs investigation of the social and behavioral
aspects nf population, there is no reason that the Center
or lis .-.uccessor, given adecpiate leadership ami staff,
rannot support a sufficient program in tliese areas a-s
well.
.Another reason that social and behavioral research
has not been sufficient has been the general scarcity of
liiiids for all tyiH'S of population research. In fiscal year
1'.)712, only $(;.7 million of the ,$39.3 million spent on
population research was devoted to behavioral aspects.
Keicnt estimate-, are that federal support for social and
behavioral research in population should be increased
over the ne.\t several years to a total of about S50
million annually.' (See Chapter 11 for discussion of
research into methods by which individuals may control
Iheir ferlillly.)
Research is needed on a broad range of topics in
the behavioral sciences to develop the knowledge
required for the formulation of population policy
objectives and effective means to achieve them. A major
eiomponent of this research must be directed toward
increasing our knowledge of the effects of population
changes on the many factors that determine the quality
of life in the United States, such as economic growth,
resources, environmental (|uality, and government
servire,^.
Since the effects of |)opulation change are diffuse
and per\,islve, the research tpieslions are numerous and
'..iried. The many gaps in our knowledge are abundantly
1 le.ir in this Report. Many others are reflected by, and
indicated m, the background papers commissioned for
this Report, which will l)e published in several
volumes.' The following paragraphs are intended only
to illustrate the research needed.
Research on the consequences of population
change must deal not only with population size ajid
rat^s of change, but also with childbeanng patterns (as
reflected in ages at marriage and parenthood, lengths of
intervals between births, and so forth), changing age
composition, shifting geographic distributions, changing
patterns of metropolitan and nonmelropolitaii
residence, increasing scales of social organization,
density, and the like.
Studies shouki not he limited to "macro"
phenomena, but should also explore the consequences
of population dynamiis at the family aiul individual
level. For example, an iini)ortant set of |)roblem-
involves the immediate and long-term consei|uences, to
mothers as wAi as children, of births to unmarried
women. Other questions requiring investigalion deal
with the effects of family size and child-spacing patterns
on the health and development of children.
The consequences of various migration patterns are
of great importance to our society. For example, ho^'.
do movements from rural to urban areas affect the
quality of public services available in areas of origin and
destination? How do great increases In the number of
people in a jurisdiction affect the relationship of I he
citizen to his local government? How do various
patterns of residential use affect the physical environ-
ment? What are the likely consequences of projecteil
population decline in many metropolitan areas, asso-
ciated with national population stabilization? Without
answers to man>' of these questions, it is diffi(;ult to
formulate reasonalile policy objectives, either locally or
nationally.
Also within the field of population distribution,
research is needed which more clearly differentiates the
factors |)erpetuating residential segregation. Racial
discrimination is clearly an Important factor, for even
when economic differences between races ai'e taken into
account, residential segregation persists. I'rejudici' is not
the only manifcslation of racial discrimlnalioii. There
are also institutional barriers whicli o|)erate to keep
racial mlnoritii>s segTegated resldentially. These barriers
need to be specified and their effects understood.
Another broad area of research requiring further
development involves the determinants of population
trends. Knowledge of the causes of population change is
needed to permit the formulation of poinilation policies
that have a reasonable chance of helping us to achieve
263
our oiiji'ctuea. For t^xaniple, at tin.' prr'ii'iit lime, it
apni'jrs tl'.aL if all coupl.-s had effective L-uiitrol of their
fertihly, ul- nii'ihl achieve fertility rates consistent vvuh
the replacement, rather than the continued increase, of
our population. Ilowever, v;e do not know wliether
ctirrent family-size preferences will change, and we
know little about what causes these preferences to
change. Following World War 11, the United Slates, as
well us a number of other developed countries. e.\peri-
enceil a substantial rise in fertility after a century of
decline. We luulerstand 'very little about why thi,->
hap|x>ned, and we cannot be certain that a simil.ir
Ijlienonienon will not occur ai^ain.
At the family aiid^ individual level, much more
needs to be known about the factors affecting the
control of fertility. We know, for e.\aniple. that stronaly
MKjIivated couples can limit Iheir fertility with relatively
iiieffr'i tive ( ontrnce|)tive measures. On the other hand.
I'veii ulieii hn;hl\' effeclive measures are available, some
couples have several uninteiuled concept ions. I'here are
man> theories about the factors affectinu ^ticces,^ or
failure in the control of fertility, but little solid
kno.%,edee.
An imp'Ttajit area of research mint involve lii"
family as a dynamic' institution. Nut only do specific
families change through the years, but the nieanin!; and
the fi.iiictions of the institution itself clianae, .Since
population [)henomena (births, tleaths. anil misjration)
inevitably involve the family, a major emphasis on the
fanidy i^ necessary in any research on the causes and
consequences of population change. This will also
netes,arily lead to research on the changing roles of
women in our society arid the effects of these changes
on the family ajid on reproduction.
Finally, increasingly important areas of research
involve studies of the effectiveness of governmental
prciams and policies that affect population change. Of
major importance now are family plajinina services. To
what e.\tent are they reaching the people who need
them'' To what e.\tent are they helpins couples (o
achiev.' (heir family ^i^e and child-spacing coals'' Dn
The research neede.l in the so.l.il ririd l>.-riavii>rai
sriemes will refiuir- the ex|,...rti^e of many disciplines:
demoera[)hy. soi lolosy, e. onomic;. iuuhropology.
p-.ycholoi£y. history, er-ography. and political science.
To encoiirag" anrl facilitate this re.^earch and research in
basil rejiroductive physiology and development r)f
methods of fertility control, a number of interdiscipli-
nary population research centers should be supported in
universities and other nnnuovernmental centers. In fiscal
year 1972. federal support for such centers was onlv
.51.5 million. Fstimates are that about .SU.5 million
should be made available annually for this purpose
within the next five years." With the concerted efforts
of natural and social scientists in such centers and
elsewhere, we can build a solid foundation for int<>lli-
sently dealing with population-related problems in our
society.
///(• Ci>imni\sii>ii ri'fnuiiiiriii/s ihiil siihsiniiliiil
iinrc'isc^ ill tcilcnil fmiih lie imiilc iiiriilnlile
fur s'iciiil u'kI hrliriiiiinil rc\canh rciilfd In
/iii/niltiliiin i;nin(li tiiiil disirihiiiioii, anil jiir
llic siipi'iiri (If luitiiinveniiiieiiiui /in/uiliiiiitii
icicanli icnicrs.
The Comraission on Population
Growth and ths .American Future,
Final Report: Population and
the Amsrican Future. VJashington,
D.C. U.S. Goveminent Printing
Office. 1972: 132-134.
Ill
lir.'rl th
itrai
pr;,.li
M.
il morl.ililv F
f.i;-:il-.
M.I mmr.
1 1 1 o
11..- \.
. ;,;:M,
!''(■( [■■ ;
r'U -
lin
se\';,;i
oeiiav
lor ani.1
(le(
pro^M,
aii.Ml
and mil
1 if we ;
rl l.r.llr
imi
ire
lil affect in.
e r|iie~l lo
i>t I. --in
.111(1 futii
l.lIllltV ,1!
264
Our purpose in appearing today is to present and support a specific perspective
concerning directions and policies of the federal government in biomedical and
behavioral research. This perspective arises from a background of 29 years of
investigation of the human reproductive process. The work began in 1946 at
Washington University School of Medicine with laboratory interest in conceptive
physiology and rapidly moved to the clinical treatment of infertile marriages,
in 1953, contraceptive physiology became a major laboratory interest and finally
in 1954 the full cycle of investigative interest in reproductive biology was
established with onset of research in human sexuality. The beginning studies
of basic anatomy and physiology progressed into clinical Interests in new techniques
of psychotherapy for sexual dysfunctions, psychosocial factors in sexual behavior,
and more recently, clinical and laboratory studies of the neuroendocrinology of
sexual response.
Although studies of reproductive biology in Its restricted conceptive and contraceptive
sense have been well -recognized and Increasingly supported in the last decade by
government policy, meaningful research In human sexuality and sexual functioning
in human sexuality and sexual functioning has been woefully ignored. This
fear of cultural opprobrium was easier to comprehend historically in the 1950s
and even the 1960s when sexual function was regarded by many well-meaning
and highly educated people as an unmentionable topic. However, even in this
decade, with a new openness on the part of the general public coinciding with a
265
rapidly increasing and totally understandable demand for secure information, with
obvious priority being given to the issues of notional and international population
planning, and with wide exposure given the subject by all forms of the media,
definitive sex research still has continued to be hampered by lack of adequate
funding support. . •
The experience of the Reproductive Biology Research Foundation in applying
numerous times for federal funds and being consistently turned down led
to discrete inquiries concerning these failures. Informed sources have repeatedly
told us that meritorious work has been unfunded because it was either too controversial
politically or because the concept of sex research was offensive to one or more
individuals on the review committee.
Finally, in December, 1974, our first federally-funded research grant in 12
years was awarded. Since this was for a study of reproductive physiology and
drug use, we still must wonder how important the lack of involvement of sexual
material in this project may have been in allowing its approval.
The basic point we would like to make is that the sexual dimensions of life are
so broad, with so many biomedical and behavioral implications, that national
research priorities can no longer afford to neglect this area. Although there will
be those individuals both within and outside of government who bristle at the mention
266
of the subject of sex, we cannot adequately implement human population planning
without better knowledge of both sexual behavior patterns and sexual physiology;
we cannot speak realistically of improving the quality of life in this country when
literally millions of persons are or will be sexually dysfunctional due to such
physical disabilities as diabetes mellitus, neurologic disorders, alcoholism, and
drug addiction and abuse. We must seriously question the public health implications
that a purposefully maintained ignorance of the potential reproductive consequences
of drug use and abuse entails. Finally, we must recognize the wide gap between
results returned from research using animal models and adequately controlled
human investigations if we are effectively to approach these problem areas.
We would like to present some examples of new research directions we believe
to be important to the topics of today's hearing. As recently pointed out by
Dr. Robert Dupont in the area of drug abuse, one of the most alarming changes
to be recognized has been a trend toward use of more concentrated and
pharmacologically potent forms of cannabis by an increasingly younger population
of school-age children. Educators, scientists, and government officials are well
aware that their reports of marihuana usage by an increasingly youthful population
are not isolated instances of experimentation, but that there is solid evidence of
frequent and continuing drug exposure by many high school, junior high school,
and even elementary school students.
267
Investigations in the past two years In several animal species and in man have
documented that chronic use of marihuana can cause significant depression of
circulating testosterone, alteration of pituitary gonadotrophin levels, impaired
spermatogenesis, and possibly diminished growth hormone reserve. Theoretically,
such alterations in the endocrine system might disrupt the normal sequence of
pubertal development with adverse sequelae Involving both physical and psycho-
social maturation. Yet no research has been done to ascertain the facts of these
theoretical risks that could result from early and frequent exposure to cannabis.
Although we have preliminary evidence that acute administration of cannabis
can produce hypothalamic-pituitary suppression in women, there Is a paucity
of investigative data concerning the possible influences of this widely used drug
upon the female reproductive system. Pubertal development, fertility, pregnancy,
and lactation in the human are obvious areas requiring inquiry. Several experiments
with animals have shown diminished lactation associated with cannabis use, but
surprisingly this factor has not been studied as yet in the human.
While still discussing cannabis research, we would like to emphasize the importance
of gathering more detailed Information in the areas of genetics and cellular damage.
With no expertise to judge presently available data, we would make a plea for not
confusing discrepancies in findings between Investigators with reason to by-pass
further study. If a drug can alter spermatogenesis and cellular DNA content. It
Is imperative that we understand how this occurs and what the consequences might be,
268
Other drugs of abuse. Including heroin, morphine, methadone, and barbiturates
have been found to lower plasma testosterone levels in men and cause alterations in
sexual functioning. These same drugs are known to produce endocrine changes in
women, as well. Further description of definitive information in these areas may
ultimately be the best educative tool available to dissuade individuals from use of
illicit drugs. However, such information will only be available when adequately
designed studies are planned and performed, and it is unlikely that this will occur
without major federal financial assistance and full administrative coordination.
Alcohol research should, ideally, lead to a means of identifying the population
most highly at risk for alcoholism and then provide a means for lowering this risk.
However, practical aspects of alcohol research cannot be dropped while waiting
for such breakthroughs. Therefore, we would like to mention several issues we
believe to be of importance in dealing with this major public health problem.
Although clinicians are fully cognizant of the deleterious sexual effects of
alcoholism, almost no reliable research has been done to document the prevalence,
natural history, etiology or treatment of these alcohol -created problems in sexual
dysfunction. While there currently is no basis for even guessing at the degree of
sexual dysfunction in alcoholic women, we estimate that 40 to 50 percent of
alcoholic men are or will become impotent. If we conservatively assume that
there are 5,000,000 alcoholic men in this country, there are probably 2,000,000
men who are impotent due to alcoholism alone. Surely this is a significant public
health concern.
269
Previous studies document clearly that alcoholic men with cirrhosis have lov/ered
testosterone levels. However, no careful study of the endocrine status of the
alcoholic without significant liver damage has been carried out to date. New
evidence is appearing that alcohol may significantly affect spermatogenesis, but
as yet no reliable information regarding ovulation in female alcoholics is available.
To repeat a similar point made earlier, it is now apparent that alcohol is another
drug being used with greater frequency by adolescents and pre-adolescents. The
possible consequences of alcohol abuse by this group in relation to normal pubertal
development also requires study. In both the cases of alcohol and marihuana use,
large-scale prospective, controlled, longitudinal studies would ideally be performed
to evaluate the problem. The methodologies are now available for doing these
studies without difficulty, but government interest and financial support seem to
be lagging.
A major area of government initiative and spending in the past decade has been
population planning. This has been an uncomfortable region for some because,
understandably, it is difficult to separate sexual behavior from procreation.
Nevertheless, it seems to us that all too often the significance of sex research
as an integral part of population planning has been either downplayed or ignored,
at some cost to the efficiency and effectiveness of the work in population control.
270
when accurate information is not available to the public concerning the potential
sexual consequences of the use of various contraceptive methods, the void is '
quickly filled by myth and misconception. As a result, people may refrain from
using a particular contraceptive method or may avoid any use of contraception
entirely. There are innumerable instances where misconception has led regrettably
to unwanted conception.
The research approach to population planning has seemed to plateau recently,
although current methods are far from Ideal. An area that seems particularly
important to us is one first described by the Reproductive Biology Research
Foundation in 1961 with a report of the existence of a naturally-occurring
intravaginal "lethal factor" that is strongly spermicidal. Although further study
of this phenomenon has been slow, current laboratory capabilities should greatly
assist in determining whether this "lethal factor" is biochemical or immunologic
and In developing its potential as a contraceptive. Concomitantly, separate
but directly related studies of the biochemistry of human vagina! and cervical
secretions throughout the menstrual cycle with relation to Infertility problems
should also be conducted.
Necessarily, further research into effective, safe, economical and aesthetically-
satisfactory male contraceptive methods needs to be pursued. Our understanding
of the exact mechanisms responsible for the regulation of spermatogenesis is still
271
very incomplete, but without more secure endocrine Information in this regard it
is unlikely that major advances in male contraception will occur.
Whenever there is discussion of research or treatment, there is an implicit
responsibility for all concerned to be aware of the ethical implications of such
work. The very personal nature of human sexuality magnifies this responsibility
for sex researchers. To call national attention to this matter, the Reproductive
Biology Research Foundation is sponsoring a conference in January of 1976 on
Ethical Issues in Sex Research and Sex Therapy. Every health-care profession,
as well as the legal profession, will have major representation at this first
conference in the ethics of studying human sexual behavior. It is our hope that
subsequent to this conference, sex research will cease to be prejudged as callous,
unscientific, or even frivolous.
As you may surmise from this testimony, we have put strong emphasis upon the
need for endocrine studies in many different areas. For several decades,
endocrine research has largely focused upon metabolic and biologic events. It
is our belief that the next decade will see exciting and important expansion of
endocrinology into a discipline dealing with the interface of hormones and
behavior. Careful planning of biomedical and behavioral research will be
necessary to encourage this expansion.
272
TESTIMONY OF THE SOCIAL SECURITY ADMINISTRATION - SEPTEMBER 29, 1975
Biomedical Researcli and Health Care Costs
01 ifton R. Gaus
Social Security Administration
As an official with the Medicare program, my interest in biomedical
research may puzzle you. Medicare does not finance or engage in biomedical
research. It does, however, finance the results of this research. The
diffusion and adoption of health care innovations often results in the
utilization of far more resources than was initially expended in the
research effort and the process plays a major role in the dramatic
increases in the open-ended budget levels of the Medicare and Medicaid
programs. For this reason, the Social Security Administration is
intensely interested in research funding strategies adopted by the
National Institutes of Health.
The long term cumulative effect of adopting new health care
technology is a major cause of the large yearly increases in national
health expenditures and in total Medicare and Medicaid benefit levels.
Technology is defined here in the broadest sense to include new diagnostic
and therapeutic techniques regardless of whether they use new medical
hardware or instrumentation; e.g., the development of new drug therapies
is considered technology.
As shown below, Federal Medicare and Medicaid benefit expenditures
have been rising at tremendous rates. Their projected annual increase—
$5.2 billion in FY 77--will probably exceed the rest of the HEW health
budget (including the National Institutes of Health).
273
(In billions'
Aggregate amount
Amount of increase
Program
FY 1975
FY 1976 1/
FY 1977 1/
FY 1975-76
FY 1976-77
Total
Medicare
Medicaid
$21.0
14.1
6.9
$25.0
16.9
8.1
$30.2
21.0
9.2
$4.0
2.8
1.2
$5.2
4.1
1.1
V Actuarial projections
It is not just Federal programs whose costs have been expanding at
a high rate. In the ten years ending fiscal 1975, all health expenditures
increased from $38.9 billion to $104.2 billion, growing from 5.9 percent
of the GNP to 7.7 percent. V
Total
Per capita
Fiscal
year
Amount
(in
billions)
Percentage
increase
Per capita
amount
Percentage
increase
Percent
of GNP
1965
1966-.
1967
1958
1969
1970
1971
1972
1973
1974......
$ 38.9
42.1
47.9
53.8
60.6
69.2
77.2
86.4
94.2
104.2
8.3
13.7
12.3
12.7
14.2
11.5
12.0
9.1
10.6
$197.75
211.56
237.98
295.20
333.57
368.25
408.81
441.94
485.38
7.0
12.5
11.1
11.7
13.0
10.4
10.9
8.2
9.8
".9
9
..2
6.5
6.7
7.2
7.6
7.8
7.7
7.7
]_/ Nancy L. Horthington. "ixational Health Expenditures, 1929-74," Social
Sec urity Bulletin , February 1975.
nk
A large part of this enormous increase in health expenditures is
due not to higher unit prices for health services but to more real
resources being utilized in the health sector. Much of these added
resources are related to new technology. This is particularly true
of the hospital industry. Expenditures for hospital care rose from
$13.2 billion in 1965 to $40.9 billion in 1974. It is estimated that
at least half of the increase in hospital expenditures is related to
more intensive use of real resources. 2/ This intensity factor
includes hospital payments to amortize new equipment and facilities
and for the employees to provide higher levels of services. Thus, of
the planned Federal Medicare and Medicaid hospital expenditures for
FY 1977, approximately $7.9 billion will go for a level of service that
was not in existence in 1967.
No one disputes- the need for adopting new services that lead to
improved health status or relief of pain and suffering. The problem
is the magnitude of the increases, and when taken cumulatively, the
extent of their value relative to the share they consume of the
Federal budget. When these increases for intensity are compounded
over the ten-year history of Medicare, they mean that the intensity
of service a patient now receives in a hospital day are twice those
received in 1967; yet is the patient twice as healthy? Is there a
better use for the billions of dollars that account for greater
intensity of health services? I obviously do not intend to answer
my own questions, but someone should.
21 Office of Research and Statistics, Social Security Administration.
Medical Care Expenditures, Prices, and Costs: Background Book (in process)
2 75
Somewhere in the public policy arena responsibility must be taken -
for overseeing the process by which resources are added to the health
care sector. NIH or for that" matter, the Federal government, need not
play the entire role, but some role is indeed warranted. Many NIH
research funding decisions appear to be million-dollar decisions at
the time they are made, but turn out to be billion-dollar decisions
when the outcomes of the funded research reverberates through the
health care system.
For example, the amount of Federal research support aimed at
renal dialysis technology was quite small. -With the extension of
the Medicare program in 1972 to those under age 65 with end-stage
renal disease, the results of this research effort will directly
account for over $1 billion per year of the 1980 Federal expenditures.
Other innovations with a potentially similar impact on health
care resources appear on the horizon. The artificial heart is still
in the experimental stage. In 1973, the National Academy of Science
estimated that the national resource cost of treating end-stage heart
disease by implanting an artificial heart would range from slightly
less than $600 million per year to somewhat more than $1.75 billion
per year. _3/ Obviously, economic input into research funding decisions
related to the artificial heart should be made within a far larger
context than simply the dollar funding level of the proposed research
effort.
y Institute of Medicine. Disease by Disease Toward National Health
Insurance . National Academy of Sciences, June 1973.
2 76
Biomedical research can impact on Federal and national health
care expenditure levels in more indirect ways as v/el 1 . The overall
cumulative effect of health care technology in this country, in
combination v/ith hospital-oriented, cost-based health insurance, has
been to encourage the shift in the health care system away from
office-based, primary care medical practice and toward the more
expensive hospital-based, specialty-oriented practice.
During the 1940's and early 1950's, technological changes in
health care was synonomous with new drugs which could often be
dispersed on an ambulatory basis, were highly effective against
pneumonia, influenza, tuberculosis and other infectious diseases,
and which had major impacts on morbidity and mortality related to
these diseases. In recent years, the thrust of technological advance
in health care has changed. New advances are usually resource
intense, necessitate institutionalization of the patient, and have
only a small impact on general health or even on the morbidity and
mortality related to the specific disease at which the technology is
directed.
These are typically "half-way technologies," attacking a disease
after the fact and largely at a symptomatic level. Examples of this
trend include chem.otherapy and radiation therapy in cancer treatment,
renal dialysis, coronary bypass surgery, organ transplants, and
intensive care units for heart attack, burn, and traumatic shock.
Since these technologies often require an institutionalized patient.
277
the hospital becomes the focal point for amassing the needed machines
and labor. Even those treatments that can be done at least part of
the time on an ambulatory basis (e.g., radiation therapy, renal
dialysis) are often concentrated in the hospital setting. Of course
this is also the result of our public and private health insurance
coverage v/hich provide better coverage in the hospital.
Costly new technologies are rapidly diffused in the health care
system. In a regime of full cost reimbursement there is little
incentive on the part of the patient, the hospital administrator,
or the physician to create a situation favorable to the adoption
of resource-saving technology. Instead, perverse incentives tov/ard
the adoption of resource-using technology are present. This phenomena
is reinforced by the strong technological imperative instilled in
physicians via their medical training programs, particularly our
hospital-based graduate training (internships and residencies) that
focus on health care in an institutionalized setting and teach
dependence on costly technology.
Even today, many years after their introduction, there is ongoing
debate concerning the efficacy of many of these treatments. Unlike
pharmaceuticals, which are not permitted on the market until after they
have been extensively tested, new medical procedures remain on the
market until they are found unsound or possibly irrelevant.
I do not have a hard fast cure for this complex problem, but will
offer some thoughts on where we should be headed. Simply put, vigorous
economic analysis and tests of efficacy and efficiency must increasingly
278
enter the biomedical research domain in 3 separate areas: (1) assessing
current medical practice; (2) evaluating new techniques not yet
diffused; and (3) allocatingmedical research dollars. This would
produce valuable information for very difficult societal decisions in
the future concerning who shall live and who shal l die. However,
information alone will not solve the resource allocation problems of
the future. A new mechanism must be created so that the public is
heavily involved in these decisions and is educated to accept the
fact that while science may be capable of saving lives, the economy
may not be able to afford it. The remainder of my paper will deal
with information needed for these allocation decisions. I will leave
the problem of who makes the decisions up to others.
ASSESSING CURRENT MEDICAL PRACTICE
Many treatment modes are currently practiced as a matter of course
with no hard evidence to support their efficacy or efficiency. Radical
mastectomies are a case in point. < The United States is the only
developed country where physicians favor radical over simple mastectomies,
Surgical fees run almost twice as high for the radical procedure, yet
until recently, no tests were performed to determine if one procedure
had higher survival rates than the other. In the last few years,
randomized clinical tests of these procedures have been taking place.
It will be some years before the results can be fully assessed, but
indications are that the radical procedure does not have higher
survival rates. If this is the case, much pain and dollars would have
been saved had these procedures been tested sooner.
279
Many other procedures require similar testing. For example,
physicians are still unsure of the value of tonsillectomies. One
generation ago this procedure' was undertaken as a matter of course.
Gradually, people have become aware that it is not the panacea it was
once considered and, as with all surgery, some danger exists as well.
However, tonsillectomies still represent a major portion of some
physicians' practices. In two similar communities in New England,
tonsillectomy rates are ten times higher in one community than the
other. 4_/ People are paying for these operations, either through
taxes, insurance premiums, or directly out-of-pocket. It certainly
would "pay" to determine if these operations were necessary.
Similarly, multi-phasic screening is fast becoming standard
operating procedure, yet no one has proven conclusively that the
number of diseases discovered is worth the cost of the screening, nor,
for that matter, that discovering these diseases leads to any improve-
ment in health status. Such a determination should be made before
continuing on our current course.
With the implementation of PSRO's, the need for testing current
practices is even more immediate. PSRO's are responsible for determining
accepted modes of practice. Without supporting data, these determinations
will be made in the dark, and current practice will automatically become
approved practice. If, on the other hand, procedures are tested for
efficacy and efficiency before PSRO's lend their stamp of approval,
V John E. Wennberg and Alan Gittelsohn. "Health Care Delivery in Maine
I: Patterns of Use of Common Surgical Procedures," The Journal of the
Maine Medical Association , May 1975, Vol. 65, No. 5.
280
optimum medical care vnll become the standard and cost-savings will
result; savings that could be plowed back into research and translated
into improved health. Responsibility for this testing is not of issue
here. Whether MIH undertakes this responsibility or it is located
elsewhere in the Government, a systematic, concentrated effort must
be made to examine current medical practice, and the biomedical
research community should be involved.
EVALUATING NEW TECHNIQUES
Economics must also enter the picture when an innovation is first
developed, prior to its diffusion in the health care system. Technological
change does not necessarily mean improvement, nor does improvement
necessarily mean economic feasibility. In this cost-conscious era of
limited resources, the question "Is it worth it?" must be asked.
Development of the heart transplant technique is an innovation with
positive results--the prolongation of life. But at what cost? How
many more lives could be saved with the same amount of resources spent
elsewhere? These questions must be addressed before techniques reach
the public. For a new drug to gain FDA approval today, the drug industry
must not only prove that the drug will cause no harm, but also that it
must do some good. This kind of test should be applied to all new
medical procedures and even carried one step further. The additional
step would require proof that an innovation is economically efficient
as well as efficacious.
281
Once a technique is adopted by the medical community, it becomes
difficult to conduct studies and even more difficult to institute
change. For example, the Mather study in England suggested that persons
with ischemic heart disease fare better at home than in coronary care
units (ecu's). However, when the data were first presented to the
scientific community, the figures were reversed, resulting in a strong
reaction that such testing at home was unethical and should be stopped
immediately. When the correct figures were displayed, no such reverse
reaction occurred--CCU's were not declared unethical and no one suggested
sending all patients home. 5/ True, the study was far from conclusive,
but the story demonstrates the difficult psychology in changing techniques
once they have a stronghold in the medical community.
Tests for efficacy and efficiency should be conducted on new
procedures prior to adoption and diffusion. NIH acknowledges that
clinical trials of new findings should be a part of their budget and
their mission. They recently sponsored an issue paper on clinical
trials and agree with the recoTjnendations supporting such efforts. MH
has begun such activities in their Cancer Control Division. Part of
this Division's functions is to initiate field tests and demonstrations
of promising research results, evaluate these for effectiveness and
efficiency, and then disseminate those findings which meet certain
evaluation criteria. Why not extend these activities to all biomedical
research developments?
bj A.L. Cochrane. Effectiveness and Efficiency, Random Reflections on
Health Services , The Nuffield Provincial Hospital Trust, 1972.
282
ALLOCATING MEDICAL RESEARCH DOLLARS
Efficiency criteria also need to be applied prior to undertaking
research activities--in the determination of where the money for
research should be spent. Allocation of such funds in NIH is
currently based on d variety of factors, primarily the chances of
success and politics. Decisionmakers at top levels of the allocation
process--among institutes and among programs within institutes--need
to be armed with information on the costs and benefits resulting from
major proposed endeavors.
When decisionmakers are looking at the' "chance of success" as a
criteria for allocating funds, they must also look at the outcome of
that success as well. If the chances of success in one area of research
are the same as in another, the resulting lives saved or treatment costs
avoided must be looked at as well.
Similarly, when Congress is debating how much money to allocate
each institute or which diseases should receive special attention, they
need far more data than they currently receive in order to make rational
decisions. Pressure from special interest groups and personal experiences
of Congressmen and their constituents with certain diseases, should not
be the only factors in policy decisions. Congress needs objective data
on the costs and benefits of different budget allocations in biomedical
research.
The Social Security Administration has made a small step in this
direction. In a study soon to be published, SSA has examined the cost
of each major diagnostic category and described the method of estimation.
283.
Costs are calculated for detection, prevention, and treatment, as v/ell
as lost productivity due to illness, disability and premature deaths.
The findings show that illness cost the Nation nearly $190 billion in
1972. §J As the attached table demonstrates, cardiovascular diseases
represented about one-fifth of the total costs, and neoplasms about
one-tenth. Nevertheless, examination of the Federal Budget reveals
that allocation of research funds is the reverse--cancer receives
about one-fifth and cardiovascular diseases about one-tenth. Providing
decisionmakers with such data but in more detail might help in future
spending decisions. But more is needed.
All specific diseases of research interest must be costed out in
a consistent manner. NIH has started to do this with several diseases
but in a sporadic fashion. Furthermore, the cost of a disease alone is
not enough justification for funding it. Benefits or outcomes such as
lives saved, hospital and disability days saved, or treatment costs and
earnings saved from possible prevention or treatment innovations must
also be looked at. It is not enough to say stroke costs the Nation
X dollars, so we must give substantial support to its research effort.
We must consider that research into a drug that would decrease
hospitalization of stroke victims 50 percent would save X dollars
compared with development of another treatment which would save two
times X dollars. At the same time, however, we must also consider that
research into another disease striking fewer people may lead to a method
6_/ Barbara S. Cooper and Dorothy P. Rice. The Economic Cost of Illness
Revisited . Social Security Administration, ~(in procesTy!
284
of prevention that wipes out the disease entirely. The savings there
may be even greater than that of a treatment for stroke and this
possibility must enter in allocation decisions. In other words, tne
possible economic results of a research breakthrough should be
considered before funding it. Economics should not become the sole
criteria for research funding, but it should not be ignored either.
In summary, the health care cost increases experienced in the
last decade cannot and will not continue forever. As the Medicare and
Medicaid budgets grow by leaps and bounds, increases in the other HEW
health programs, including biomedical research, become more limited.
Since biomedical science is partly the cause of these large increases.
It should play a role in assessing the value of current medical
procedures and in preventing the premature adoption of uneconomical
technology. Only through this intensive evaluation of medical practice
is there any hope of nationally controlling health cost increases. It
is the Social Security Administration's hope that your panel will
highlight this need in its report.
285
■fr us GOVERNAAENT PRINTING OFFICE 1976 O-207-615
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